Talk: Why Therapy Fails?

I am busy preparing for my talk for BIG in Bury Mental Health Group on “Why Therapy Fails”.
The topic wasn’t my choice but one that is so close to my heart. This reflects my hypervigilance for failure which is a mixed blessing but also because I am so committed to putting people at the centre of what I do. I don’t want people to be in a process that isn’t helping and not likely to help.
The risk of dropping out of therapy is always there but never more so than when therapy fails to deliver benefits.
But being too ambitious in therapy can also be unhelpful. One of my first clinical supervisors warned me “Your desire for people to have good outcomes might get in the way”. What he meant was that they may feel pressured into improving and might even say they are improving when they are not.
Currently I am exploring possible research into better preparing people for therapy.
Later I will reframe the question and suggest that therapy never fails, but before then I would suggest that the best person to ask is the person who has attended therapy.
In general, I would list the following as reasons why therapy doesn’t work (at a particular moment in time).

General reasons
• Wrong therapy. Despite some claims that CBT is the “best thing since sliced bread” it may not be the most appropriate. Person centred counselling can help people who are having relationship problems or in dire situations where it is almost legitimate to have negative thoughts and feelings.

Bereavement counselling does what is says on the tin and may be the best approach.

For those with very troubling emotions and who habitually respond to difficult situations in an unhelpful way may find dialectical behaviour therapy better.

People from troubling backgrounds whose defences get in the way of their relationship may be lucky to and get psychodynamic therapy.

• Wrong focus. People often present with multiple problems and both therapist and person can get bogged down. It is easy to be unwittingly mislead into treating depression when anxiety is the issue.

• Wrong time. People may not be in the right frame of mind to make best use of therapy. No amount of therapy can rescue people who are in the most harmful of situations although support may help a person move out of such situations or challenge those responsible.

• Wrong therapist. Without blame it may well be that the therapist is not the best match with that person. Gender, cultural background, age. Therapist may be too optimistic or pessimistic.

• Wrong pace. Therapist may be too pushy ie “not collude” enough. They may be too ambitious. They may be too cautious. They may terminate too quickly.

• Wrong place. Work conditions for the therapist may be too toxic to make therapy succeed.
How can we help prevent failure?
1 Not offer it. Is the right time and therapy for the person?

2 Selection of people to become therapist. Is the would be therapist a person likely to collaborate, be helpful, be compassionate, contain, reflect, learn, refrain from blame.
3 Good training for therapist. Training should help a person deselect themselves or if needbe be failed.
4 Good supervision for therapist. Supervisor needs to be both compassionate, honest and committed to their role of quality assurer.
5 Good conditions for therapist. Matchup of person and therapist. Therapist has right number of people (not overwhelmed by number of clients).
6 Lighten up and recognise CBT can be “critical”.

Reframe the question as “Therapy can never fail”

As long as … therapist and person is willing to reflect and explore and learn from reasons why, on this occasion, therapy didn’t work.

Research
Plenty of research to draw on much around skills/qualities of the therapist.
Age, experience and training not always associated with positive outcomes. A willingness to collaborate and arrive at mutually agreed goals for therapy associated with positive outcomes.
Lambert, M. J., & Ogles, B. M. (2004). The efficacy and effectiveness of psychotherapy. In M. J. Lambert (Ed.), Handbook of psychotherapy and behavior change (5th ed.). New York: John Wiley & Sons
Norcross, J. C. (Ed.). (2011). Psychotherapy relationships that work (2nd ed.). New York: Oxford University Press.
Wampold, B. E. (2010). The basic of psychotherapy: An introduction to theory and practice. Washington DC: American Psychological Association
Management of so called ”therapeutic ruptures” is important if therapy isn’t going to break down.

Safran, J. D., Muran, J. C., & Eubanks-Carter, C. (2011). Repairing
alliance ruptures. In J. C. Norcross (Ed.), Psychotherapy relationships that work (2nd ed.). New York, NY: Oxford University Press