What would therapy look like if therapist followed this protocol?

I agree that they set it up to be infantilizing and go out of their way to avoid admitting how dangerous therapy can be

that was part of the issue with my T, i wanted to have the discussions about the phenomenon of transference/ counter transference and how it was coming up in my therapy and often tried to bring up the concept when it first started happening. but in true T fashion, he would dodge or side step the discussion and try to turn it back onto me. so i resorted to learning about it on my own through my own research or from other's personal accounts on the forums.

as budfox said, T treating me this way did feel a infantilising or that T did not trust my level of intelligence that i could understand the concept and not have it interfere with his agenda to use the transference that was playing out.

My point is that transference is not an issue for everyone nor does every therapy modality focus on it. It was a non-issue.

Just because a modality doesn't work with transference doesn't prevent it from happening. And while it's not an issue for everybody, therapists have no way of knowing which people might be affected by it. The ethical thing to do would therefore be to make some sort of disclosure on the topic so that the client would know what they are consenting to.

I don’t disagree though I doubt it would make much difference. Most sign off disclosures of possible complications all the time without hardly a thought.

Where is the prospective client supposed to get reality-based info? Other than a few obscure blogs, books... the available info is almost entirely pro-industry propaganda and orthodox therapy scripture. You have to be very determined to find anything else.

Informed consent doesn't have to be as simple as the ridiculous sheets of paper used by therapists. It is true that most people just sign those without reading them. But it doesn't have to be that way. For example, when I've had surgeries, my surgeons haven't just had me sign some sheet of paper talking about the risks of the procedure. They've sat me down and explained things, asked if I had any questions. When my psychiatrist prescribes a new medication, she also tells me what I can expect and what sorts of things I need to contact her about if they happen. I don't just sign a consent for treatment once on the first visit when seeing a surgeon or a psychiatrist and then never actually have any sort of discussion with them about the risks of the treatments they provide.

Of course. But even after knowing the risk factors almost everyone goes on to have that treatment, that medication, that Surgery, because the alternative of not getting that service is worse. The lack of data is unconvincing.

The very, very few instances when we’ve personally rejected a treatment were when a) the hard data showed a high likelihood of serious complications, and b) in those instances, even the treatment provider did not recommend the treatment because they could predict, based on evidence, that those complications were a pretty imminent risk.

A therapist that knows basically zero about a new client has no data or evidence about that client to give that kind of firm warning. They can only discuss vague possibilities which are unlikely to be persuasive to someone who has come in desperate for help with anxiety or depression, etc.

I have rejected medical treatments and my person rejected medical treatments as well. The balance of benefit versus side effect or potential worse damage is very much something I consider. Fortunately for me, I was highly skeptical of therapy and therapists before I began. I shudder to think of the damage that could have been inflicted upon me had I not been so wary. It took two years of my constant questioning to finally get the woman to admit she had no idea if she would be useful to me or not. In fact, she knew all along she didn't know this - but she only admitted it after 2 years - why? Her dishonesty did not cause me to trust her more - in fact it was the opposite for me.

I'm not at all convinced that almost everyone goes on to have treatments, Artley. There are tons of people who refuse to take psychotropics, for instance, because the side effects were worse for them than whatever the condition it was that the medication was treating. Can I personally relate to that? For the most part, no, because the side effects for me are milder than my mental illnesses. I do avoid some meds because I know there is a correlation to dementia. But that doesn't invalidate the fact that many people find medication side effects not worth it, and there is plenty of hard data on that. As for rejecting treatments due to likelihood of serious complications, I have no idea what the statistics are on that. To me the important thing is that people be informed so that their autonomy is respected and they can make the choice whether they want to do something or not. Because a minute risk is still a risk. I had surgery on my ankle a few years ago. It was very low risk and I don't regret it. However, I did develop a very painful blood clot afterwards, despite being very low risk and starting a low dose aspirin regime immediately post-op. If I hadn't known about the risk of blood clots, I would have thought I was just having post surgery pain and I could have died. So I have personal experience being part of the teeny tiny minority statistic of unlucky people who suffer the unexpected adverse consequence of treatment. Again, I don't regret the surgery, but I would have felt rather blindsided had I experienced something like that and nobody told me it could happen ahead of time.

The therapist knowing anything about the client is unnecessary. And I don't know what you mean about it being persuasive. It's supposed to be informative, not an argument for or against anything. The assumption that someone will not pay attention to the information is not a justification for the failure of the therapist to provide it.

i agree that it's not easy to find the information, especially if you are a therapy virgin and don't even know what information you are looking for in the first place. i was close to being in crisis when i entered therapy and definilty not in the fame of mind to be researching all the potential therapist, modalities or who would be the best fit or even 'ethical', let alone feel that i even had the time to do that...i was desperate and in emotional turmoil. my first T ended up being the only T out of a handful of Ts called who actually answered their phone and said 'come in and see me'. none of the other Ts even bothered to take the time to return a call when a voice message was left for them and from other client stories, this is not all too uncommon of an occurrence when seeking the help of a T.

i didn't have the motivation to start researching potentially better Ts until well into that first year of a less than stellar therapy experince with my first T who i clearly started to realise was not competent to be working with complex truama, let alone a dissociative disorder. with my second T, yes, i did have more time to research him and i was not in such a desperate frame of mind upon first meeting him, and regardless of my researching efforts, unfortunatly therapy with him still didn't quite turn out like i had originally hoped for.

so, i'm not quite sure what the best answer is to finding a 'good' therapist, especially for someone new to therapy and who may currently be in quite a precarious state of mind. to me, and what i read of others experiences, sometimes it seems more like it's pure luck...

It isn't that these protocols aren't smart ideas and at least there is some information being given. I don't think anyone really disagrees with that kind of information. I'm just not sure it will make that much difference for most people, particularly right on that first meeting with a therapist. It isn't like a medical treatment where they have generally pretty hard data on percentages for side effects, complications, risk factors, etc. Do they have a firm profile the of the type of client prone to problems with transference? Even if they did, would they be able to profile a client in the first session? Or would this be something discussed over time (which is already the way it tends to work anyway if the therapist is tuned in)? Would this be a process required for every client, and if so, do we get comped for the waste of session time for those of us that it absolutely never applied to, because this isn't something that can be covered in a quick 5 minute warning discussion. I didn't have time to give up for an issue that there was no indication would ever be a problem for me. I was suicidal. I was extremely depressed. There were bigger issues. It was MUCH more important that the therapist work with what was truly presenting in front of him at that moment.

No easy answers on this one.

Personally, if a therapist started with me from the first session outlining all the negative possibilities, etc. without even knowing me, I would have been aggravated; I might not have returned. Where would that have left me? I went into therapy quite young, very unaware of anything about therapy. The warnings would have probably been beyond my internal comprehension or ability to focus at the time, and would honestly would have frustrated me because I simply wanted help. It would have seemed presumptuous for that therapist to have warned me about things that probably were way down the road and only vague possibilities for me based him knowing absolutely nothing about me. And sure enough . . . it wouldn't have been a factor anyway.

I needed help. I needed a therapist to help me manage my depression and deal with the aftermath of sexual abuse. I needed immediate help, not to have help in any way put off with vague warnings. I needed support and I found it . . . and it helped. So . . . if I had been warned and chose to avoid therapy due to some vague warning, honestly, I would have ended up dead. That's not melodrama. That's just the reality at the time.

It's complicated. There are no easy, no black and white, solutions here. My therapists used their judgment to work with the individual who presented in front of them at the moment. That is what I expected and needed at the time.

I disagree and think it is that simple. They have a duty to warn clients and most of them fail at that miserably. I certainly didn’t seek one of them out to let them paternalistically and condescendingly choose what they thought I could handle or not handle it any given time. I consider that to be the height of arrogance on their part. I completely reject the idea of paternalism as a positive.

Again. I didn't say that the protocol idea isn't a good one.

Are you suggesting that I am in any way implying that we should be shooting for paternalism and condescension in a therapist? If so, please don't misrepresent what I am saying. Nowhere have I said such a thing.

I am saying that a therapist deciding not to warn of the dangers of therapy because they don't think clients can handle it or because they are substituting their judgment or deciding what a client needs or doesn't need- is paternalism and is condescending to clients. It is that simple. And it is an approach I find offensive and horrifying that they act in that fashion

Yes, that would be a poor therapist. I've never had a therapist do that. I HAVE had therapists talk to me about why they would like to proceed the way they are planning to proceed and hear me out about my questions and concerns, letting me make the decision about whether I am comfortable with that plan, etc. I've never had a therapist behave dictatorially, even when I was in crisis. I realize it happens but, like you, if a therapist, doctor, or any service provider dictated rather than discussed, I'd be out of there. That's really not what I was talking about. That was your take on what I was talking about.

You are misinterpreting me. I said nothing about dictatorial. I meant what I said earlier. You and I will never agree on this.

I agree with pretty much everything that Artley has taken time to spell out here.

Although I can understand from where the idea of a comprehensive informed consent comes from, I highly doubt it would accomplish anything close to what people seem to hope here. A good therapist will lay all the necessary information out in due time anyway. For the not so good therapist, the informed consent would provide just a very convenient cover that will help to officially roll the responsibility on the patient's shoulders - you were informed and you consented, so why are you complaining?

If I think back abut myself in my first therapy session then the most important thing for me was the vibe I was getting from the therapist - does he seem to understand the problems I'm presenting that I don't understand myself and no one else ever before understood about me? And yes, he immediately saw something in me that rang true and is quite obvious in retrospect but that no one else had seen before. I did not know anything about the therapy at that time and if he would have started to go through some very elaborated informed consent that definitely would have been very hypothetical for me at the time then I probably would have figured that no, he cannot help me and thus I simply wouldn't have found the help I have actually received.

Also, I believe many things have happened in my therapy that my therapist had never experienced before in his work and thus he himself has had to learn and adapt considerably in the course of my therapy, too. That means that he possibly even couldn't have given me informed consent about those things because he simply did not even know that things can go that way.

I generally don't believe in strict protocols in psychotherapy, except perhaps when it is in fact skills teaching. Psychotherapy is based on a relationship between two people and this just cannot be standardized into protocols. Yes, one might try to do that but those therapists, who understand the underlying processes, don't need these protocols and for others, who actually do not understand the underlying processes - the protocols do not help them to start understanding them and thus it's useless and perhaps rather even harmful.

Then they shouldn't try to sell it as a science or part of western medicine. If they want to admit they are just stabbing and guessing and messing with people - I am all for that.

I have never thought that psychotherapy is part of science or western medicine. Sure, some parts of psychotherapy perhaps can be studies scientifically but all these studies seem to be in their infancy still because the subject matter is just so complex.

At the same time I don't think it means that therapists (at least not all of them) are randomly guessing and messing with people. A solid accumulated body of clinical knowledge and experience also goes a long way.

I think it's fine for those of you for whom psychotherapy-as-usual has worked to say that it has worked for you and you like it the way it is.

But are you not hearing how it has hurt others? Sometimes very badly? If heard at all, there seem to be several responses to that.

1. It's the client's fault.

2. It's the therapist's fault -- they are poorly trained, incompetent, or even unethical -- but that doesn't affect the overall view that psychotherapy-as-usual is fine. There are incompetent people in every profession.

3. I just don't believe that people who claim to have been harmed by therapy actually have been. They just need more therapy.

Anything else?

HT, but right now it's not about not hearing how things have hurt others.

It's about whether such protocol with such informed consents would help to avoid hurting people. I don't believe it. I just see no way how adopting such rules would help anything substantially. It's not related at all to the points you brought out.

But, I have been harmed by psychotherapy-as-usual and I do believe it is worth a try.

When I was a "Therapy Virgin" if on the first meeting he went through the warnings of transference I would have thought in my head.."Dude...your are not even my type nor would I want you for a parent. Ewww you wont have to worry about that happening to me." I would not have believed it.

I do like the weekly check ins regarding any feelings of transference coming up so the client does not feel shame and aguish trying to bring it up themselves leaving it to fester until exploding point.

Then we can just agree to disagree. I don't believe it's worth it and I would probably filter out any therapist who would try to do that because for me that would signal those who are just following some kind of protocol and to me that signals incompetence.