Article: Clients that Didn't Get Better

Many Ts insist that they are not and cannot be "friends". I think they overdo this. A little more friendliness might result in a more lasting relationship and better results for the patient in the long run. I feel that the patient gains little from a hostile relationship that terminates early and badly, however "therapeutically sound" it might be.

I don't know. For me, being friends and being friendly are two completely different concepts but to my mind, neither of them is necessarily appropriate in therapy.

I don't think it would be a good idea for therapists to offer friendship to patients. That's not their role and although there might be certain rare exceptions, in most cases it will probably be disaster for the therapy. I.e. it will not be a therapy but a paid friendship, which to my mind would be unethical.

At the same time, I don't think therapists should necessarily be friendly all the time. Sure, they should never be hostile and they should be respectful and as non-judgemental as possible. But being friendly is not always appropriate. For instance, if I actively hate my therapist at a moment then I would perceive being friendly disrespecting my feelings.

Well then, we disagree! I found the detachment to be hurtful and had several nasty ruptures.

I don’t know. For me detachment and not being friendly are not synonyms. I completely agree that detachment is hurtful. I’m not sure though how it relates to being friend or friendly. These seem to be all different dimensions to me.

You know this topic of friendship has not been talked about in such b/w terms in my therapy.
If I've expressed desires for something like "friendship" (which I don't think I have) T normally explains why it wouldn't work in a gentle, considerate way.
I think I once laughed that a house was for sale close to her and I said I could buy that and see you walking up and the road.
T smiled and said, Thst would be painful for you.
Shes never put it that she doesn't want to be friends, but has always phrased it in way that. Shows me what it is in therapy y I need and how the way we do it gives Me the best outcome.
As the years have gone on, the relationship between us has got "friendlier"? She has let me know that therapy whrn it ends wont end completely. Ie, I there will always be contact.
That's because of the work we've done. The issues I brought.
Some only need a body there to help them think things through and ending isn't an issue.
I came with so many unmet needs that T has had to use all of herself to help me, into the work.
I guess it depends on what our therapy work consists of.

I am all of these things, and therapy didn't help me until I made intentional decisions to truly let my therapist see what was going on and to be very honest about my thoughts and feelings - even when they are embarrassing or go against my urge to self-protect with concealing. It's really hard, and it's a decision I have to make over and over and over.

Thanks for sharing this! The full paper is really interesting, and seems to me to put the blame for treatment failures squarely where it belongs--on therapists' lack of skill/poor decisions in dealing with certain clients.

I identify strongly with how the clients are described in the paper, and have had several bad therapy experiences that in retrospect seem to fit into that mold, where because I was good with words and seemed generally introspective (albeit in a somewhat intellectualizing way) the therapist thought things were going well at the beginning, only to later get bogged down and stuck in fruitless repetitive conflict because the therapist wasn't able to productively draw out and/or engage with deeper emotional material. They also often blamed me for being distant or resistant when their interpretations fell flat. In hindsight I was often (mostly unconsciously) distracting the therapist with superficial content I knew they'd find interesting that wasn't really relevant to my core issues, and their failure to recognize that maneuver set things down an unproductive path.

Fortunately my current therapy is a stark contrast to those experiences--my current therapist consistently notices and draws upon the emotional undercurrents in whatever content I bring to the table, doesn’t blame me for things that are his responsibility, doesn’t get distracted by things he finds superficially intriguing, and recognizes that therapy is a long process and that openness and vulnerability are hard work.

The thing I always found most alarming was not that those guys don't know things - but that they don't recognize that they don't know something and blithely skip along assuming they do or ignore the client who is shouting "you are not hearing even where you think you are listening"

so many times i felt like that small and desperate toddler standing at my ex-Ts feet tugging on his pant leg just begging for him to 'see me' and acknowledge my distress or what i was trying to convey. he failed to register what was right in front of him. as if he was often off in a completly different universe then the one i was living in *sigh*

I totally get that.
I've finally come to the point where I'm willing to do what's asked of me in therapy and in my DBT IOP, no matter how stupid it sounds, because the scientific literature on the subject shows that it helps people, so I put my faith in the process and the people with decades of experience, whether or not it seems stupid to me.
I take a zicam if I feel a cold coming on, knowing full well that it has no benefit vs a placebo in double blind trials, but also knowing that a placebo works even if you know it's a placebo.
It doesn't have to make sense that it works, as long as it works. And all these experts and all these studies say that it does. Trying to reason my way out of my mental illnesses clearly hasn't worked so far, so I'm going to try their way and actually try it in good faith (as much as I can... some of the mindfulness exercises are just too stupid to take seriously... I'm not going to thank my internal organs)

I've been doing that with my current T and now my IOP for the first time. It's really really hard. I got through many years of therapy with different therapists hiding that stuff. I wish my T knew the exact right questions to ask so that I didn't have to be the one to put it out there, but he's not a mind reader and won't know what the problem is unless I tell him. Then he can ask questions.

I'm glad it sounds like therapy started to help you after you began doing that.

I did this, and got shamed and rejected. How to tell a competent T from one who is not is apparently not a skill I had going into therapy. I self-revealed too much and ignored/dismissed/invalidated my own urge to self-protect. Perhaps not surprising, then, that I did not get better? But I was clueless and kept going back for more (trauma), convinced it was all my fault in the sense of my issues. Until that "logic" was just too illogical, even for me.

This sounds very good, like you are working with someone who knows what they are doing! Good for you, and for them.

In my case, I seemed not to have a clue how to find someone who could really help, and kept ignoring (not seeing) the signs that I was being hurt, as I had learned to hide them from myself and others growing up. I was just a person, with a history, looking for "help" and no pretense of expertise. It's great that some within the profession know what they are doing, but a profession in general that does nothing about those within the profession who ignore or don't see the signs that they are hurting people, has serious flaws, in my view. It's too much to expect from consumers that are -- or maybe experienced as -- half-people that we will see the harm that is being done to us. An inability to see that is exactly part of the problem that I went into therapy with. And how many others, who aren't on PC? Who is asking them?

Once again, glad to see the article, even if the general view of people whom some therapists experience as "half-people" is somewhat derogatory.

I too got shamed and rejected for being honest And I didn’t just leave the first, second, third.... time this happened

It’s the therapist who is incompetent, “sad” etc for shaming me

I read the article with great interest, especially the patient's experience of the alliance as "artificial" while the therapists described the patient as intolerant of emotional closeness with them.

I had absolutely no idea what this means though ( the no-body part??).

To those who mentioned feeling "too smart for therapy" - I've felt that too (and it's a really, really hard thing to talk about, because it *does* feel obnoxious to say). I've actually mentioned it to this T... not in those words, but I've mentioned being in the (ugh) "gifted program" growing up, and that there seems to be very little research on the types of things that might come along with being in that group. I think there's something there.. but the conversation didn't really go anywhere. I've actually got a book that I've been meaning to read, but haven't gotten to it yet...

Unfortunately, it's not something that most Ts seems to learn about, or study, or that anyone really talks about. And, I don't know if it even plays in to what this research was looking at.

Thanks Cinnamon_Role... - you're right, it's a really good start that my current T is willing and able to talk about this stuff without taking it personally. Most of my previous ones weren't able to do that, and it led to less connection. That's interesting that your T is the first that's been willing to mention this to you! It's sort of crazy, isn't it?!?!

I think for me, part of what's so hard is that my sense of myself and my emotions feels almost discontinuous... I mentioned this to her. I've read a little bit about "ego states" and that makes sense to me... that I just fall into this puddle of emotion for a short period of time (i.e. despair, crying, misery) and then when it's done, it's almost unreal and not connected to my current experience. It makes it hard to talk about, b/c it doesn't feel real... it feels like I'm just making something up, I guess. It's weird.

re: Safety and caring, I'm not even sure what I need, that's the kicker. I have no clue why some people manage to hit those buttons so easily, and others can't.

How do you like your T's way of interacting with you? I think that part of the problem (this time!) is that my T can be very... eager. Jumping in, ready to say something! I end up feeling talked over (but we're working on that). But, it still feels like... we're not on the same page. Maybe that's the crux of it - even if she changes how she interacts, it still feels like her questions aren't really *helpful*. They don't feel like they lead me towards any great insights. I don't know, maybe I'm judging her too hard here? But there's something... argh!

You know the feeling when you're having a great conversation, and you're really in sync with the other person? You can tell that they're *getting* what you're saying, and their questions make you go, "Ooooh! Yes!!!! Exactly!!!" and think of 10 other things. I don't get that from therapy Does anybody?

Thanks...

Toomanycats - thanks. That's a good point (about deciding to let your T see what's going on). Really hard... especially when *I* can't always see it. I think that's part of the problem...

Starfishing - wow. You sound like you've got such a good handle on what was happening in your past therapy, and such a great (skilled!) therapist now. Do you mind if I ask what type of therapy you're doing now? I'm curious (because it's come up for me a couple times) if it's more psychoanalytical? It just *seems* like the psychoanalysts may (maybe?!?) have a better handle on this stuff, but maybe that's just the impression I have from reading (I've never seen one in person). Thanks!

I think though that the point you (and others) have made that being open/vulnerable is hard work is important. I think that, with some of my past therapists, there's been... reactions from them about things that I say. Reactions that make me feel either not heard, or judged, or not good in some way... it's *really* hard to continue to try being open, especially with even harder material, after that!

Stopdog - 100% agree!

SalingerEsme - Maybe the hyphen was a typo, and they meant "nobody"? I'm not sure though... the idea that the more important the therapist became, the less they were treated as a person... seems off to me? I don't know... when I think about pulling back from the therapists that I've seen, it was NOT because they were important to me, but because I was completely freaked out. I was *scared* - so I pulled back and limited interaction as a way of self-protecting. And, part of why I was scared was because they all seemed very pushy... they didn't do a good job of respecting boundaries when I said that I didn't want to talk about stuff, and I felt like I was going to get pushed into things that would make me decompensate, with no real support, help, or understanding.

Here Today - I totally agree.

It's really hard. And, it's even harder when you consider that some Ts might be competent with some issues, but not others, and the issue of personal "fit" (how well you and your T "mesh").

I don't know the answer either. It kind of feels like there's a subset of us that T's just don't know how to properly treat. And, it ends up being hurtful in the end. I'm not sure, going in, how one can possibly know if a T is going to be able to handle their issues (especially considering a lot of people have issues that they're not aware of until they get far along in therapy).

I think that a T "doing their own work" (i.e. seeing their own T) would be a good start - so that they can process what they need to, and not get overwhelmed by counter-transference. I want to think that older, more experienced Ts may have an edge here too - but I'm not sure. My last T definitely felt like he could handle it if I were to get angry at him... but I don't know if that was his age, his own personal therapy-work, or just his personality. He had a kind of tough/gruff demeanor (to me) that made therapy hard... but it definitely felt like, if I needed to tell him off, he could handle it and not be personally hurt/upset.

New T keeps telling me that she doesn't take things personally (because I hate having to tell her when something she's doing is making me feel worse). I still feel mean doing it though!

It's true--I'm incredibly lucky, and it's honestly a bit astonishing what a difference it makes to be seeing a therapist whose skill level seems to be quite a bit higher than many I've seen in the past.

Well said. There should be more protection for clients from therapists who are unskilled, who refuse accountability, who do harm (whether out of ignorance, incompetence, carelessness, or malice). No matter how well informed, people seeking therapy are at a huge disadvantage when it comes to figuring out if the therapist is actually capable of helping them, and people are fed way too many messages implying that all it takes for a therapist to be a "good fit" is basic goodwill and decent intentions, rather than recognising that it's a difficult and complex job to do well and that some therapists are just not capable enough to do good work with certain clients.

The defensive, client-blaming, self-serving way many of the therapists in the paper described their non-improving/deteriorating clients is really striking and infuriating.

I wonder about this too. I was also in the 'gifted' program growing up, and would consider myself to be above average in intelligence (at least in the academic sense).

I've usually felt smarter than the therapist I sat across from. The most helpful therapist before the one I had now had a similar intelligence level to me. But again, I wouldn't say this to anyone because it sounds douchey as f***.

Now, for the first time in my life, I have a therapist who is much, much, much smarter than me. After fifteen years of therapy off and on, I've finally found someone who can put things together that I can't. I know I've lucked out.

It also helps that I can make a reference to any book, and I know there's an 80% chance he's read it.

It's depth therapy, if that helps (Jungian and transpersonal).

Well, it's much easier to see what was wrong/lacking with 20/20 hindsight! At the time I was often just confused and frustrated that things didn't seem to be going anywhere, while agonizing (and often self-blaming) over the fact that I didn't feel like the therapist(s) understood me at all.

Yes, you're correct! I'm currently in psychoanalytic therapy twice a week, and I very much agree with you than his psychoanalytic training and approach are a significant part of why my current therapist is better equipped to work with me effectively, given the particular difficulties and resistances I have with being vulnerable

Oh yes, it can be so incredibly painful to put so much effort into opening up and then feel like that effort is disrespected, or like the therapist is judgmental.

Count me in... I once had a cbt therapist who always wanted me to get my IQ tested. I never did, never thought that it would do me any good with regard to my emotional problems.. I felt more like a study object but not like a human being... Still, once in a while she did have some interesting insights.

Her theory was, that little me - most probably what would be called a "gifted child" nowadays - had trouble processing her emotions all along, right from the start. But being too smart for my own good, I started compensating through my cognitive abilities. Not just plain old intellectualizing, but trying to 'understand' emotions through my intellect. I really used to try to find "rules" (or algorithms) with regard to others' emotional behaviour that would be puzzleing to me, and that I didn't get at all. But I was good at finding patterns, thus realizing if the person says abc, me saying xyz might be an appropriate response. Trouble is: There is no rule without exception/s. And also: Those are pseudo-emotional responses. Ultimately they're fake. I guess I got pretty sophisticated in creating those pseudo-emotions, but basically, it's me trying to guess what is expected of me, and not me living in congruence with my innermost self. But I lived several decades without ever realizing that there might be a difference between those two...

I know this 'feeling' of disconnection. Once the moment has passed, the emotion feels so terribly unreal, and it is impossible to get back into that state of mind, no matter whether it's positive or negative... Current T puts it down to some form of mild dissociation, that's always there, almost like an undercurrent... Which the article talked about as well.

What a lot of Ts just don't get: It's not a choice. It's not a choice to stay disconnected. I just cannot help it. The rupture with ex-T came about because she kept insisting that I should 'own' my anger. WTF ? I didn't even know what anger she was talking about? And she kept implying that I just refuse to talk about it, out of defiance. And I kept searching myself, whether she might be right, but I simply couldn't get hold of the anger. Which I rationally know *must* be there, definitely. But I cannot feel it, at all. So in the end I just couldn't take that any longer...

I think my current T and I are still in the getting to know each other-stage. But I like her openness. Her willingness to reflect herself and her perceptions and to share those. It feels like 6 months with her have shifted more inside of me, than 6 years with all the rest of my Ts. She has got this eagerness, that you talk about. And yes, sometimes she'd interrupt. Or sidetrack. But she's pretty good at catching herself when she's doing it...

When I read this article I kept wondering whether this is because in the T's narrative the conversations with those clients were perceived as invigorating, and exceptionally stimulating etc... So when I feel like this in a conversation (with friends etc) I'd get so excited about my ideas, that I sometimes cannot wait for the others to finish their sentence... At the same time we have talked a lot about my tendency to mirror, or to become an emotional chameleon to whatever person I'm interacting with. So I guess in backpaddling, when she would love to chip in her thoughts, she is trying to give me the space to really explore what I am feeling. Which is a challenge, for sure. Both for me and for T. Because when I'm in that space, things will get tedious. Slow. Tiring. It's hard work in the truest sense... Really hard work. Because trying to hold a connection to my emotions that was never to be, is like exercising some muscles that you never really used much... And I know it is a challenge for my T as well, since she feels the pull towards my functioning persona as well... So it's easy to drift back on that level, if we're not both keeping watch in that regard....

I guess, the thing that makes it "bearable" for me right now is communication, and meta-communication (ie communication about our communication). Which really helps her to understand how I perceive things, and my world, and myself in this world. And how I perceive her.

Thanks again guilloche for sharing this article and sharing your thoughts in that regard.

all the best, c_r

Thanks Starfishing. That's really cool that you're doing psychoanalysis. I can easily imagine how his training/orientation is a big help for this stuff. My experience has been so many Ts just... get caught up in the counter-transference (I think?) and end up feeling personally *bad*, when really it doesn't have a lot to do with them, and we'd both do better if they could identify it for what it is and deal with it, rather than react. (I had a T who was a lovely, kind woman... but cried in session one day, as she told me that she *knows* she's a good T, but apparently couldn't understand why she wasn't able to help me? It made me feel so sad!)

tomatenoir - Thanks! It IS helpful to hear about your experience, and the type of therapy that your T does. Again, I can only imagine (with some slight jealousy!) what it's like!

It's weird to me, because I don't think my current T is stupid. She may actually be smarter than some of the previous ones (she does like to throw the word "perseverate" around, which makes me gleeful, even though it's not a very flattering description of me!) But, sometimes... I point out something, and she seems surprised and hadn't thought of it, but it seems so obvious to me. Like how, with something that I went through with my last T, it was ironic and painful that my issue specifically had to do with not having a voice, and my T cut me off and wouldn't let me talk about it!

I wish there was more research into this stuff (for grown-up "gifted" kids), because it does feel like there's something there... but what do I know?

tomatenoir and Starfishing - how did you guys find your Ts? And, did you know immediately that they were going to be more helpful than previous Ts, was it obvious early on?

Thanks!

Thanks Cinnamon_Roll. Very interesting insight into how you learned to adapt to not being able to process emotions well as a child! And, ugh.... that sucks that your ex-T thought you were purposefully refusing to discuss the anger. Isn't that just the silliest feeling, trying to figure out how to discuss something that you don't actually feel in the moment? My T has broached anger a couple times, but always backs off when I tell her that I'm not sure...

re: Jumping in... my T has told me that she notices that I get annoyed when she interrupts (ya think?) - which is a little surprising, because she's also told me that she can't read my emotions at all. (As an example, just a week or two ago she mentioned that when she puts my upcoming appointments in to the calendar, she's never sure if I actually want them scheduled! I don't understand this at all... I've never canceled on her or talked about leaving, even though I HAVE discussed whether psychoanalysis might be a better fit. It's frustrating - because again - it feels like this pattern of a T starting to feel "not good enough" playing out!)

Jumping in because of excitement makes sense, but isn't very helpful! I'm glad your T is giving you room to process... mine is trying to.

It's funny though, I asked her last week if she comes from a family that interrupts and talks over each other. (My family doesn't - we wait until someone pauses before jumping in). On reflection, she said yes, and that when her husband first met her family, he found them a little intimidating because they were verbally boisterous with everyone talking at once (which would drive me crazy!).

Then, she said that I know more about her than any of her other clients (?!?!) which seems completely bizarre. I don't know much at all, and asking about how her family talks didn't feel overly personal - it felt like a meta-conversation about how people talk, and why each of us has certain expectations in our conversations, and why she's doing what she's doing, even though she apparently can see that I'm annoyed

Hmm... that makes me wonder if that's part of the "awkwardness" she's feeling. If she's used to people interrupting her back, and I don't... maybe it makes me look even MORE reticent than I actually am?!

I think the only thing that makes life anywhere near bearable or tolerable for me right now is people with the ability to listen, unlike more than three therapists (irl). And unlike the family of origin. I’m not just a bunch of walking labels. How freakin boring. It disgusts me when they try to reduce a human being to a bunch of derogatory labels.

I don’t have the money to pay another therapist for 7 years

I don’t have the energy to feed them for 7 years, only to be turned on and treated like garbage.

I didn’t have the skills to assess a competent therapist. Maybe I do now but not if I’m muzzled.

Well, not quite psychoanalysis--it's "only" twice a week (hah), and while we've discussed using the couch I'm sticking with sitting up face to face for now. But I don't think there's that much of a difference between psychoanalytic therapy and psychoanalysis when it comes to this particular difficulty. I've seen (good and bad, though mostly bad) therapists who worked psychodynamically before, but my current therapist is the first who's also an analyst. A lot of why I work well with him is doubtless unrelated to that--he's also a good fit personality-wise, and he has another area of expertise that's unusual to find that's important to me. But I also don't think it's a coincidence that he seems to have a much better grasp of countertransference issues than people I've seen in the past.

And where some past therapists seemed to take my difficulties with vulnerability and/or other resistance personally, and either got openly frustrated/upset or tried to bludgeon the resistance away, my current therapist has taken an entirely different approach to figuring out where the resistance is coming from, respecting its utility, and only pointing it out directly when therapeutically useful. Which I now realize is a therapist’s whole damn job--making sound judgments about when and how to bring something up or make a connection vs. recognizing when it’s not the right time! My current therapist is of course not perfect, and he makes mistakes like any person does, but he treats the whole endeavor of therapy with the carefulness and skill I feel like it needs, and is open to the possibility that when there are issues he could be the one causing them.

A stroke of mostly luck, where I was looking for a psychiatrist who took my insurance and recalled a name a friend of a friend had mentioned in another context. When I then looked him up, I liked what I read (including some published papers that I found interesting and insightful) and I decided he might be worth talking to even though he clearly preferred to do therapy rather than just the med management I’d been looking for.

It’s funny you should ask whether it was obvious early on that things were a good fit, because it was actually weirdly intensely obvious. It sounds kind of ridiculous and impossibly cheesy, but there was a moment halfway through the first evaluation/consultation session where I distinctly thought to myself that this was what I needed, and that I could imagine looking back on this appointment someday as the beginning of something significant. Which has weirdly proved to be the case. That said, with a previous therapist who was very helpful, I hated her passionately for at least the first month or two. So there’s obviously a variety of different ways that can go!