Dec 4, 2023
Why Therapy
Fails
One of the most common reasons patients contact me is to find
out why the therapy isn't working. They may be TEAM-CBT patients or
patients of therapists using other approaches. Therapists also ask
for consultations on the same problem--why am I stuck with this or
that patient who isn't making progress?
In the Feeling Good App, my colleagues and I have been looking
into this as well. Most app users report excellent and often rapid
results, but some get stuck, in just the same way they might get
stuck in treatment with a therapist. I have tried to organize my
thinking on this topic, because if you can diagnose the cause of
therapeutic failure, you can nearly always find a solution. Of
course, the app is not a treatment device, but a wellness device,
but the same principles apply.
So today, Rhonda, Matt and I discuss a couple reasons why
therapists and patients alike sometimes get stuck. Matt described a
patient who was misdiagnosed with a psychotic disorder who turned
out to have sleep apnea. When the proposer diagnosis was made and
treated, the patent suddenly recovered.
Rhonda described a patient who jumped from topic to topic and
always brought up a new problem before completing work on the
previous problem. This problem was solved when Rhonda explained the
importance of sticking to one problem for several sessions, until
the problem was resolved. The patient then began to make
progress.
David described a depressed woman from Florida who was stuck in
treatment, and not making progress, and then the therapist said "I
just can't help you," This hurt and confused the patient who wrote
to me. There were essentially two problems--the patients depression
what brought her to therapy in the first place, and her unresolved
hurt feelings when the therapist "gave up" on her. This problem
reflected many failed relationships is the patient's life. This was
resolved when the patient took the initiative to schedule a session
to talk about the conflict more openly with excellent results.
In addition, the patient had heard that she "should" accept
herself, but didn't know how to accept her constant self-critical
troughs and intensely negative feelings. I suggested she make a
list of the benefits of her negative thoughts and feelings, as well
as the many positive things they showed about her and her core
values as a human being.
She came up with an extremely impressive and long list! For
example, her criticisms showed her high standards, her humility,
her dedication to her work, her accountability, and much more. In
addition, she'd achieved a great deal because of her relentless
self-criticisms.
I asked her why in the world she'd want to accept herself, given
all those positive characteristics
She decided NOT to accept herself, and was delighted with her
decision. She said she felt profound relief!
An unusual, but awesome, path to acceptance! In other words, she
ACCEPTED her "non-acceptance."
I hope you find today's podcast interesting and helpful. Of
course, ultimately therapy is part science and part human
relationship art. That's why Rhonda and I offer free weekly
training groups for therapists who wish to develop their
therapeutic skills. The groups are on zoom so therapists from
around the world are welcome. Matt offers a consultation group
(free to Stanford psychiatric residents) every other Tuesday for
therapists who want help with difficult, challenging cases. To
learn more, you'll find details and contact information at the end
of the show notes.
When Therapy Doesn’t
Work--
And How to Get
Unstuck
(for Therapists and
Patients)
By David Burns,
MD
Here’s are some of the most common reasons why therapy might
fail or appear to be stuck / without progress. Some of them will be
of interest primarily to clinicians, while others will be of
interest to clinicians and patients alike. And many of these
reasons will also apply to individuals using the Feeling Good App
who are stuck in their attempts to change the way they think and
feel.
But what does “stuck” actually mean? The definition, of course,
is subjective. I believe that a substantial or complete elimination
of depression and anxiety can typically be achieved in five
sessions with a skilled TEAM therapist. I use two-hour sessions,
and can usually see dramatic change in a single session, although
follow-ups may be needed for Relapse Prevention Training or other
problems the patients might want help with.
In my experience, the treatment of relationship problems and
habits and addictions usually takes much longer than the treatment
of anxiety or depression. The techniques to treat relationship
problems and habits and addictions actually work just as fast as
the techniques to treat depression and anxiety, but the resistance
can be far more intense. For example, someone may be ambivalent
about leaving a troubled relationship or giving up a favored habit
for many months or years before making a decision to move in a new
direction.
And, of course, the treatment of biological problems like
schizophrenia and bipolar I disorder will nearly always require a
long term therapeutic relationship, often requiring medications in
addition to therapy.
The problems and errors I’ve listed below are mostly
correctable. And although there are many traps that therapists and
patients fall into, the vast majority of therapeutic failure the
patient's hidden 'resistance' to change and the therapist's lack of
skill addressing it. This is true in clinical practice and in
psychotherapy outcome studies, as well.
On the one hand, a great many patients will feel ambivalent
about change. For example, a patient with low self-esteem may not
want to stop being self-critical and accept themselves, as-is, but
to have a better version of themselves, first. Or they may want to
overcome their fears without facing them. Or they might want a
better relationship but would want the other person to do the
changing.
Unfortunately, most therapists lack the skills to address
resistance and, in fact, often make it worse by trying to motivate
the patient to change, rather than understand their hesitation to
change and discuss it with them. This is one area where
TEAM training has a great deal to offer, including over
30 skills therapists can learn to address motivation and
resistance.
The following list of 37 reasons why therapy fails follows the
structure of T, E, A, M.
Errors at or before the initial evaluation
- Patient is just window shopping
- Patient does not buy into the cognitive model
- Incorrect conceptualization of type of problem, so you end up
using the wrong techniques. To simplify things, I think of four
conceptualizations:
-
- Individual mood problem (depression or anxiety)
- Relationship Problem
- Habit / Addictions
- “Non-problem”: healthy negative feelings such as the grief you
might feel when a love one dies
- Patient is not in treatment out of choice. For example, a
teenager might be brought in by parents to be “fixed,” like
bringing in your car to the local garage for a tune up, and you
don’t have an agenda with your patient. Or a parent might be
court-ordered to go to therapy if he wants to have custody of his
children.
- Failure to ask patients to complete the Concept of Self-Help
Memo, the How to Make Therapy Rewarding and Successful memo, and
the Administrative Memo prior to the start of therapy. These memos
fix a great many therapeutic problems that are likely to emerge
later on, like homework non-compliance, premature termination, and
policies about confidentiality, last minute cancelling of sessions,
conflicts of interest (eg patient is seeking disability) and more.
Most therapists ignore the use of these memos, only to pay a steep
price later on.
- Failure to mention the requirement for homework and similar
issues the at initial contact with the patient.
- Failure to explore the patient’s motivation for treatment.
T = Testing
- Diagnostic errors: not recognizing additional problems which
patient may have in addition to the initial complaint, such as drug
or substance abuse, psychosis, intense social anxiety, past trauma
or abuse, or hidden problems the patient is ashamed to disclose.
This is easily solvable by the use of my EASY Diagnostic System
prior to your initial evaluation. It screens for 50 of the most
common DSM “diagnoses” and only takes ten minutes or so out of a
therapy session to review and assign the “Symptom Cluster
Diagnoses.”
- Failure to use Brief Mood Survey before and after each session.
This error makes the therapist blind to the severity or nature and
severity of the patient’s feelings, which cannot be accurately
identified by a patient interview or therapy session. As a result,
the therapist’s understanding will not be accurate, and the
therapist will not be to pinpoint the degree of change (or failure
to change) during and between therapy sessions.
E = Empathy
- Failure to ask patients to complete the Evaluation of Therapy
Session after each session. As a result, it will not be possible
for therapists to understand their level of empathy, helpfulness,
and several other relationship dimensions critical to good
therapy.
- Failure to use the “What’s My Grade” technique while
empathizing with the patient.
- Failure to receive training in the Five Secrets of Effective
Communication and the three advanced communication techniques.
These techniques are difficult to learn, requiring lots of practice
and commitment, but can be invaluable in therapy and in the
therapist’s personal life.
A = Assessment of Resistance (also called Paradoxical
Agenda Setting)
- Failure to recognize and deal with Outcome Resistance: There
are four distinct types, corresponding to depression, anxiety,
relationship problems, and habits and addictions.
- Failure to recognize and with Process Resistance: There are
four distinct types, corresponding to depression, anxiety,
relationship problems, and habits and addictions.
- The “because” factor: I won’t let go of my depression until
“I’ve lost weight,” or “I’ve found a loving partner,” or “I’ve
achieved something special,” or “I’ve found a better job / career,”
or “I’ve achieved my goals at X.” This is another type of Outcome
Resistance.
M = Methods--errors using the Daily Mood
Log
- Patient “cannot” identify any Negative Thoughts
- The way you worded your Negative Thought. The common errors
include thoughts describing events or feelings, rhetorical
questions, long rambling thoughts, or thoughts consisting of a few
words or phrases, like “worthless.”
- No Recovery Circle / many need many techniques combined with
the philosophy of “failing as fast as you can.” This allows you to
individualize the treatment for each patient. It is simply not true
that there is one school of therapy or method (like meditation,
mindfulness or daily exercise, etc.) that will be helpful, much
less “the answer,” for all patients!
- The way you did the technique / incorrect use of technique.
Many of the most powerful techniques, like Interpersonal Exposure,
Externalization of Voices, Paradoxical Double Standard, Feared
Fantasy, and many more require considerable sophistication and
training. They can be fantastic when used skillfully, but they
aren’t easy to learn!
- Trying to challenge your negative thoughts in your head / vs on
paper or computer. This is associated with Process Resistance for
depression—refusing to do the written homework, and it is
exceptionally common.
- Trying to challenge the negative thoughts of someone else or
encouraging them to think more positively: won’t work! In my first
book, Feeling Good, I spelled out the warning that
cognitive techniques are for you, and NOT for you to use on other
people, including friends, family, and so forth. It is my
impression that many people ignore this warning. When they discover
that the person they are trying to “help” does take kindly to
identify the cognitive distortions in their thoughts, both end up
frustrated.
- Failure to “get” the Acceptance Paradox / using too much
self-defense in your positive thoughts, especially Technique when
doing Externalization of Voices
- Using the Acceptance Paradox in a defeatist, self-effacing
way
- Failure to include the Counter-Attack Technique when doing
Externalization of Voices. This techniques is not always necessary,
but can sometimes be the knock out blow for the patient’s endless
inner criticisms.
- Not understanding the necessary and sufficient conditions for
emotional change when challenging distorted thoughts.
- Too much focus on cognitive / rational techniques when far more
dynamic techniques are needed, such as the Experimental Technique
(e.g. exposure) in treating anxiety or the Externalization of
Voices or Hidden Emotion Techniques
- Not recognizing that the patient’s negative thoughts might be
valid (I think that my partner is cheating on me) and trying to get
your patient to challenge the “distortions” in the thoughts
Other therapist errors
- Codependency: addiction to trying to “help” / cheer up the
patient / solve some problem the patient has
- Need to be “nice” and refusal to hold patients accountable
- Narcissism: unwilling to be criticized, unwilling to fail,
needing to stay in the expert role
- Difficulties “getting” the patient’s inner feelings, due to
lack of skill with Five Secrets and the failure to use Empathy
Scale
- Difficulties forming a warm and vibrant therapeutic
relationship, which can sometimes result from strong (and nearly
always unexpressed) dislike of the patient
- Commitment to a favored “school” of therapy / thinking you are
superior to colleagues and have the one “correct” approach
- Failure to use assessment tools with every patient at every
session
- Failure to make patients accountable for homework
- Four types of reverse hypnosis: this is where the patient
hypnotizes the therapist into believing things that simply aren’t
true.
-
- Depression: the patient may really be hopeless or
worthless
- Anxiety: the patient is too fragile for exposure
- Relationship problems: the patient is too fragile for / not yet
ready for exposure
- Habits / addictions: not making the patient accountable or
assuming patient isn’t yet “ready” to give up the addiction, or the
patient needs to have emotional / relationship problems fixed
first
- Unrecognize, unaddressed conflicts with therapist that need to
be addressed with Changing the Focus. This error often results from
the therapist’s fear of conflict or patient anger, and is usually
accompanied by a failure to use the Evaluation of Therapy Session,
which would send a loud signal to the therapist that something is
wrong.
- Failure to do Relapse Prevention Training prior to
discharge.
- Conceptualization errors. Failure to use or select the most
effective therapeutic approach and techniques for the patient’s
problem. For example, the Daily Mood Log and Recovery Circle are
great for depression and anxiety, although there will be some
important differences in the choice of methods for depression vs.
anxiety. For example, Exposure and the Hidden Emotion Technique are
great for anxiety, but rarely useful for depression. The DML has
only a secondary role in the treatment of relationship problems
(the Relationship Journal is more direct and useful) or habits and
addictions (the Triple Paradox and Habit and Addiction Log (HAL)
are far more useful.
- The therapist may be committed to a school of therapy, like
Rogerian listening, without addressing resistance or using methods.
Or therapist may believe that psychodynamic or psychoanalytic
therapy, or ACT, or traditional Beckian cognitive therapy, will be
the “answer” for everybody. The schools of therapy function much
like cults, causing feelings of competitiveness (our guru is better
than your guru) and sharply limiting the critical thinking and
narrowing the consciousness of the faithful “followers.”
- Conflicts of interest. The therapist may subconsciously want to
keep the patient in a long-term “talking” relationship due to
emotional or financial needs.
- The therapist may have been taught that therapeutic change is
inherently slow, requiring many years or more. This belief will
always function as a self-fulfilling prophecy.
Thanks for listening!
Matt, Rhonda, and David