373: 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.

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

1. Patient is just window shopping
2. Patient does not buy into the cognitive model
3. Incorrect conceptualization of type of problem, so you end up using the wrong techniques. To simplify things, I think of four conceptualizations:
   1. 1. Individual mood problem (depression or anxiety)
      2. Relationship Problem
      3. Habit / Addictions
      4. “Non-problem”: healthy negative feelings such as the grief you might feel when a love one dies
4. 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.
5. 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.
6. Failure to mention the requirement for homework and similar issues the at initial contact with the patient.
7. Failure to explore the patient’s motivation for treatment.

T = Testing

1. 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.”
2. 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

1. 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.
2. Failure to use the “What’s My Grade” technique while empathizing with the patient.
3. 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)

1. Failure to recognize and deal with Outcome Resistance: There are four distinct types, corresponding to depression, anxiety, relationship problems, and habits and addictions.
2. Failure to recognize and with Process Resistance: There are four distinct types, corresponding to depression, anxiety, relationship problems, and habits and addictions.
3. 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

1. Patient “cannot” identify any Negative Thoughts
2. 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.”
3. 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!
4. 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!
5. 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.
6. 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.
7. Failure to “get” the Acceptance Paradox / using too much self-defense in your positive thoughts, especially Technique when doing Externalization of Voices
8. Using the Acceptance Paradox in a defeatist, self-effacing way
9. 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.
10. Not understanding the necessary and sufficient conditions for emotional change when challenging distorted thoughts.
11. 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
12. 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

1. Codependency: addiction to trying to “help” / cheer up the patient / solve some problem the patient has
2. Need to be “nice” and refusal to hold patients accountable
3. Narcissism: unwilling to be criticized, unwilling to fail, needing to stay in the expert role
4. Difficulties “getting” the patient’s inner feelings, due to lack of skill with Five Secrets and the failure to use Empathy Scale
5. Difficulties forming a warm and vibrant therapeutic relationship, which can sometimes result from strong (and nearly always unexpressed) dislike of the patient
6. Commitment to a favored “school” of therapy / thinking you are superior to colleagues and have the one “correct” approach
7. Failure to use assessment tools with every patient at every session
8. Failure to make patients accountable for homework
9. Four types of reverse hypnosis: this is where the patient hypnotizes the therapist into believing things that simply aren’t true.
   1. 1. Depression: the patient may really be hopeless or worthless
      2. Anxiety: the patient is too fragile for exposure
      3. Relationship problems: the patient is too fragile for / not yet ready for exposure
      4. 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
10. 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.
11. Failure to do Relapse Prevention Training prior to discharge.
12. 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.
13. 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.”
14. Conflicts of interest. The therapist may subconsciously want to keep the patient in a long-term “talking” relationship due to emotional or financial needs.
15. 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