Friday, 27 February 2015

What do clients think of psychotherapy that doesn't work?

Psychotherapy works for most people, but there's a sizeable group for whom it's ineffective, or worse still, harmful. A new study claims to be the first to systematically investigate what the experience of therapy is like for clients who show no improvement after therapy, or who actually deteriorate.

Andrzej Werbart and his colleagues conducted in-depth interviews with 20 non-improved clients (out of a larger client group of 134) who were enrolled in individual or group psychoanalytic psychotherapy at the former Institute of Psychotherapy in Stockholm. Seventeen of these clients showed no symptom improvement after an average of 22 months therapy, and three showed deterioration. The clients' had an average age of 22 at the treatment start, and 17 of them were female. Their problems included mood disorders, relationship problems and self-reported personality disorders. The interviews took place at the end of the course of therapy, and then again one and half years later.

The researchers transcribed the interviews and identified a key central theme: "spinning one's wheels" as exemplified by this client quote:
"When I think back on the therapy, I get the feeling that I often sat and talked; sometimes something important came up, but often it felt like it was pretty much just spinning my wheels."
What other messages were distilled from the interviews? The clients had largely positive views of their therapists, but they saw them as distant and not fully committed. A recurring issue for the clients was feelings of uncertainty over the goals of therapy and the methods to achieve those goals. Many had expected a more challenging, confrontational, structured style of therapy.

The researchers said the 16 therapists (10 female; average age 53), many of them highly experienced,  who'd worked with these non-improved clients, may have been guilty of sticking too rigidly to traditional psychoanalytic technique:
"The patients' descriptions of therapists' silence and passivity together with a focus on childhood experiences and deep roots of presented problems resemble a caricature of psychoanalytic psychotherapy, but unfortunately the picture may be accurate," they said.   
The researchers urged therapists to address their clients' treatment preferences and expectations – such reflection could have led to the realisation that a more "directive, task and action-oriented" form of therapy may have been more appropriate for these clients (conversely, other research has found that dissatisfied CBT clients tend to say they would prefer an approach with more emphasis on reflection and understanding). Clients need to be involved in setting the goals of therapy and educated about what the process will entail, the researchers added. But also, "the therapist needs to learn to be the unique patient's therapist."

Previous research has already established that therapists are poor at identifying when therapy is not working. Werbart and his team said that "formalised feedback" based on client surveys during therapy "can be a less threatening way to start discussions on negative and hindering therapy experiences."

On a positive note, between the end of therapy and later follow-up, more than half the non-improved clients showed beneficial decreases in their symptoms. Such ongoing change was not observed for clients who showed more immediate improvements after therapy, suggesting these changes were not a mere consequence of maturing. "Rather, the conclusion is that non improvement at [therapy] termination does not imply lasting symptoms," the researchers said.


Werbart, A., von Below, C., Brun, J., & Gunnarsdottir, H. (2014). “Spinning one's wheels”: Nonimproved patients view their psychotherapy Psychotherapy Research, 1-19 DOI: 10.1080/10503307.2014.989291

--further reading--
When therapy causes harm
The mistakes that lead therapists to infer psychotherapy was effective, when it wasn't
What clients think CBT will be like and how it really is

Post written by Christian Jarrett (@psych_writer) for the BPS Research Digest.


Research Digest said...

Therapists need to listen more and not assume they know it all. I have found the older they are they seem to know it all because they have seen it all. Everyone is different. It is the Genetics + Environment = Outcome equation. You must get rid of the environment as much as possible.

Research Digest said...

I would argue using a therapy based on pseudoscience is not the best way to obtain useful information on this issue...!

Research Digest said...

"Get rid of the environment"??
What a bizarre statement. Would you replace it with another, better environment, or just leave a vacuum to prevent the environment from affecting people? How are you going to determine what are the optimum conditions for someone and then enable them to access them?

Research Digest said...

The issue of causality is an important one and based upon recent observations given the diverse nature of CBT psychologists have huge potential for exploring what underpins personality traits specifically in the UK for white British nationals. This spectrum will also open up wider debate about dogmatism which exists around liberal versus conservative attitudes and a persons ability to discriminate therapeutic information. Therapists tend to resist new ideas in favour of conventionalism which can prejudice against groups in terms of social learning. Currently issues around gender in the workplace and the role of the authoritarian personality in its context; how relevant is a persons social environment?

Research Digest said...

Therapy works if you have a genuine rapport between the therapist and client, all psychological theories should be used if necessary. Also a dependency between the therapist and client must always be avoided.
I do think that the life situation and the environment will have an enormous effect on the client behavior and mental state because sometimes the clients environment contributes to the clients distress. Once removed from that situation and with therapy the client is bound to recover.

Research Digest said...

Several years ago, I spent a year in therapy with a young trainee who sought at the start to assure me he was otherwise qualified in Psychiatry. I could not get over the fact of his youth and, the self-declaration that he was already a qualified Psychiatrist only reinforced my perception that unlike myself, he was unlikely to have encountered any difficulties in his upbringing and delays in education and therefore could not possibly have a genuine insight into my circumstances. The perceived differences between us, real or imagined, served to reinforce my feelings of inadequacy and shame which led to an unsuccessful therapeutic outcome.

In contrast, 9months previously, I had my pre-therapy assessment with an older therapist more similar in age and other criteria to myself, who 'tested' me, sometimes by being kind, other times contrary. By the end of the final, third session with her, I experienced real, warm feelings for the first time in my life.

Sadly, there was no opportunity to offer patient feedback on the assessment or therapy itself. Patient feedback is an opportunity for health professionals to learn about what works or doesn't and why and could help inform a more effective spending of precious NHS resources whilst avoiding spinning that revolving door ever faster.

Research Digest said...

It’s interesting that you say ‘the life situation and the
environment will have an enormous effect on the client behaviour and mental
state’… I recently come out of therapy and after the first three sessions
I noted a marked difference and felt completely transformed, and yet never felt
in anyway dependent upon the therapist. During the second
block I started to get nervous and uncomfortable with the therapy – even breaking out into hot sweats and claustrophobia as though I was being cast in some psychological thriller; on the way out I recall feelings of great relief once in the cool open air as if I owned the whole environment. I often wonder how much therapists realise setting affects the client? From thereon I was not able to contain my composure as well and was on the verge of telling her to mind her own business... is this normal?

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