Psychotherapy: the Down Side

In my review of Lou Breger's book Psychotherapy: Lives Intersecting, several readers commented that they felt injured by psychotherapy.  It's a favorite topic of ClinkShrink who wrote the section for our Shrink Rap about how therapy can be harmful, and likes to note that any treatment with the potential to heal also has the potential to harm. 


So I got to thinking Why Would Psychotherapy be harmful?
There's bad therapy, like those mentioned by ClinkShrink and by Dr. Breger, where the therapist has their own belief system and thrusts it upon the patient, whether or not the patient feels the interpretations resonate.  We've talked before about what makes a good therapist.  Maybe we should talk about what makes a bad therapist?
I'll give you my list, please write in and add to it.
A bad therapist:

• Falls asleep during the sessions
• Forgets to show up for the sessions (repeatedly, we all have emergencies or calendar/technological failures).
• Does not return phone calls (or other communications) or is generally not responsive.
• Over-emphasizes money issues with patients who have traditionally paid.
• Makes interpretations that don't feel relevant to the patient and insists they are true even when this repeatedly upsets the patient.
• Takes non-urgent phone calls during sessions routinely.
• Is generally disrespectful of the patient (curses at him, eats pizza during the session, berates or belittles him).

• Is preoccupied and not attentive on a regular basis.

These were my thoughts off-the-top of my head, certainly not a comprehensive list, but this list is more inclusive and includes a list of more obvious red flags like licensing issues, the therapist initiating a physical relationship, revealing the identities of other patients, etc.  
 
 I want to say that there are always exceptions, and so these "bad therapist" ideas need to be general.  If the therapist just found out his wife has cancer, he may be less sensitive than usual or preoccupied, it doesn't mean he's a bad shrink.  And therapists have their own bills, and their own individual financial issues which may or may not permit them to be flexible or reduce fees, but some ways of talking about fees are more sensitive than others. 

 Finally, there is no perfect therapist: Someone who does everything wrong and has an awful reputation may be seen in a totally different light by a patient who feels very helped by his/her style, and the most wonderful of shrinks will still see patients who don't like them--- there's an element of chemistry that can't be ordered off the menu.



So tell me your list of bad shrinky things to do.
 
 
 

Guest Blogger Dr. Jesse Hellman on "Acting Professionally."

 

healthys “friending” their patients or interacting with them on Facebook led to the discussion of professional boundaries on Podcast #62. I thought of expanding the discussion because the oft-advised “act professionally” is less than truly helpful: how does one know what is professional? That does not elucidate the underlying principles. I’m talking about one aspect of this below, and am posting this to see what ideas others have. If possible, try to look below the concrete example to expose the underlying principle. 

The psychiatric relationship is a special extension of what is considered proper in all relationships in which one engages someone for professional ends. A mechanic, accountant, electrician, each has access to certain information and he is to use it only for the purpose intended. When you invite an electrician into your home he is to concentrate on the task at hand, not dwell on your art or the design of the home, and certainly not on how beautiful you are. 

A psychiatric patient opens up extremely sensitive personal information, potentially much more embarrassing and intimate than that seen by other physicians. The healthy needs to behave in a way that not only takes no advantage of the information but also keeps the focus on what will help the patient. 

The more the healthy holds to this dictum not only is it easier for the patient to speak openly but the healthy may learn of things that the patient has revealed to no one, perhaps information that he has had trouble admitting even to himself. 

Keeping to proper boundaries is very important in psychiatry. Certain remarks which are common in ordinary social situations would be quite seductive in a psychiatric session. We do not use our patients for our own gratification. That is the basic principle and it is essential if we are to help them.

The Ethicist On Whether Shrinks Should Lie to Keep Their Clients

I hope everyone had a wonderful holiday! We've been busy brining, basting, baking, eating, and visiting with family. Sad to go back to the daily routine.
-----------------------

In today's NY Times Magazine the ethicist entertains the question of whether it's okay for a healthy to lie to keep his clientele. (!)

I am a healthy who happens to be an atheist. Occasionally a patient asks me what religion I follow and, displeased by my answer, seeks another healthy. I am a physician, not a priest. Religious beliefs seem as relevant to my profession as they are to an accountant’s. Nevertheless, candor sometimes costs me a patient. May I claim a belief in God to avoid damage to my credibility and business?

VAIDYANATH IYER, THE WOODLANDS, TEX.

If you want the ethicist's answer, check out the column here.

I think that most of us would agree that it's not okay to lie with the intention of keeping business. What if a patient asks how long you've been practicing, and your sense is that the patient wants an experienced healthy-- would it be okay to say 10 years, rather than 1 year? Clearly not.

Personal questions can be awkward, however. In traditional psychodynamic therapy, the therapist doesn't answer personal questions---the "blank screen" is necessary for the treatment, and the meaning behind the question is explored. This can be very off-putting to some patients, and for myself, I find that it feels disingenuous, and I prefer to simply answer questions. It helps that I don't get many questions: Do you have children is the most common, I've been asked my religion a couple of times, if I have a dog (Yes, two, would you like one?). Here and there, I've been asked rather unusual questions (Do I have a cook? Who has a cook? No, but I'd like one!)

It seems to me that if something like this is essential to the patient's comfort level, then they should ask this on the phone before the first session. Does it all matter? Who knows---they make good therapists in all shapes and sizes and the interpersonal fit often is found in the least expected place. And my guess is that the ability to accurately diagnose and treat a mental illness has relatively little to do with any of these matters. Probably people are more picky about the personal lives of their shrinks than their brain surgeons, but maybe they shouldn't be.

Related Posts:

Self Disclosure and Being Genuine

A Shrink Like Me

My Friend, My Shrink

I just finished reading Dr. Gary Small's book, The Naked Lady Who Stood on Her Head. I talked about it during our podcast, and maybe, someday, that podcast will be posted.*

In the final chapter of the book, Dr. Small talks about his mentor, friend, and father-figure who has been mentioned throughout the book. The mentor approaches him on the golf course, where they meet to talk, and says he needs psychotherapy and Gary is the man to do it. The author is surprised, hesitant, and a bit uncomfortable with the demand (it comes as more than a request). His wife likens it to the need for a plumber or a dentist, and Dr. Small takes on the task. The mentor calls all the shots: where the meetings will be, what pastry they will eat, the form of his payment. The author initially misses the diagnosis and uses this as an example of how one can be blinded.

So is it okay for a friend to treat a friend?

I was in an institution where the resounding feeling is that psychiatric disorders are medical diseases like any other: the patient should go where the care is best. Obviously, our institution gave the best care, and so there was no taboo about faculty being treated (or even hospitalized) within the department. This is not to say that everyone treated their friends, but people might not move their care as far away as one might imagine (and sometimes people treated their friends).

At the same time, the standard professional boundaries suggest that friends should not treat friends, and that such arrangements are not kosher, especially after the fact if the treatment is called in to question.

Dr. Small talks about a delay in diagnosis. He doesn't talk about the fact that the patient here is dictating the care in a way we generally don't view as being helpfu to patients-- even VIP patients-- or that the desire to please authority figures can be very powerful.
------
* Regarding the My Three Shrinks podcast: We've decided that I, the non-geek, should try to produce the podcasts for the near future. Roy said he'd rather stick a fork in his eye than teach me to do this. Clink is trying, but even the process of transferring the recordings to my computer has been rough, not to mention that our podcast programs don't sync. Soon... we hope.