120: Ten Worst Errors Therapists Make

120: Ten Worst Errors Therapists Make

This is David and Fabrice’s top ten list for the worst errors therapists make.

1. Failure to Measure (symptoms, empathy and helpfulness). Research shows that therapists’ perceptions of how their patients feel, or feel about them, are not accurate.

TEAM therapists measure symptom severity at the start and end of every therapy session with brief accurate scales that assess depression, suicidal urges, anxiety, anger, relationship satisfaction, and happiness. This allows therapists to see, for the first time, exactly how effective or ineffective they are in every single therapy session. This can be threatening to the therapist’s ego, but has revolutionized clinical practice.

In addition, TEAM therapists assess the patient’s perception of therapist warmth, empathy, understanding, and helpfulness after every single session. The scales are extremely sensitive to therapist errors, and most therapists receive mostly failing grades from their patients initially when they use these scales, which can be a shock to the system! But dialoguing with the patient about the scores at the next therapy session can lead to breakthroughs in the clinical work and dramatic improvements in the quality of the therapeutic alliance.

2. Trying to help, “save,” “rescue” or “reassure” patients. Most therapists are addicted to this, but it simply triggers resistance. When therapists push in their efforts to help, most patients will push back. No one likes to be “sold” on anything. When patients are hurting, they want to be heard, not saved.

In TEAM we do Paradoxical Agenda Setting before trying to “help.” We emphasize, in a respectful way, all the really GOOD reasons NOT to change. We also highlight what the patient’s symptoms, such as shame, depression, panic, defectiveness, hopelessness and anger, show about him or her that’s positive and awesome, Then we raise the question: “Given all those positives, why in the world would you want to change?”

This strategy has led to breakthroughs in treatment, and I now see recovery from depression and anxiety at rates I would have impossible ten or fifteen years ago.

3. Reverse Hypnosis.

  1. Depressive hypnosis. The patient persuades the therapist that s/he really is worthless, inferior, and hopeless, and the therapist false into a trance and believes it! This dooms the therapy.
  2. Anxiety hypnosis. The patient persuades the therapist that s/he is to fragile to use exposure, or that the exposure is too dangerous, and the therapist buys right into it! This also dooms the therapy. Recovery from anxiety is more or less impossible without exposure.
  3. Relationship hypnosis. The patient persuades the therapist that s/he is the victim of some other person’s bad behavior, and that the other person is entirely to blame for the relationship conflict. Therapists almost always buy this message, and this also dooms the therapy.

4, Believing therapy must be slow and last a long time. This is taught in most graduate school programs, and tends to function as a self-fulfilling prophecy. I met a famous psychoanalyst who was proud that most of her patients had been in therapy for more than ten years, and a few were just now making baby steps, she said, toward change.

With TEAM, I usually see a complete elimination of symptoms at the first therapy session, although it has to be a double session (two hours). In addition, the recover usually occurs in a burst, all at once, in just a few seconds, or in several sudden orbital leaps during the session.

5. Believing that the purpose of therapy is to get in touch with your feelings (Emotional Reasoning). This message has been pushed for years, and was the basis of my training. The idea was that people bottle up their feelings, like anger, and then it comes out as depression. The message is still pushed today!

I’ve never seen much validity in this point of view. People can express their anger, their panic, and their feelings of worthlessness until the cows come home, but they’ll still be just as angry, panicky, and they’ll still feel worthless!

There is at least one notable exception to this rule. Most anxious patients are exceptionally “nice” and sweep their feelings under the table. Then the feelings come out indirectly, as OCD, panic attacks, GAD, or a phobia, or even as somatic complaints such as chronic pain, fatigue, or dizziness. Bringing the suppressed feelings to conscious awareness and expressing them is the basis of my Hidden Emotion Technique, and it often leads to a sudden and complete recovery from any form of anxiety.

6. Confusing your own feelings for how the patient feels. This is a psychoanalytic error. I read an article on the psychoanalytic view of empathy, which was defined as the analyst’s feelings when in the presence of the patient. This is a misguided and almost delusional notion. The analyst’s feelings are the complete creation of the analyst’s thoughts! And those thoughts will often be distorted and completely misleading.

Therapist’s perceptions of how their patients feel are less than 10% accurate if you put it to an empirical test! If you ask patients, “How are you feeling right now,” and you ask therapists the exact same question, “How is your patient feeling right now,” the therapist’s answer will usually be way off base.

The only way to find out is to use assessment instruments at the start and end of each session, like I described in the first answer above, on failure to measure.

7. Believing therapists should never express their feelings. I was trained never to reveal how I was feeling. But when you think about, that’s nutty! How can we validly encourage our patients to be more genuine and open with their feelings if we are hiding our own at the same time? Of course, there is an art form in how to share your feelings during therapy. It is a high skill, requiring training, and one that can lead to more human and effective treatment.

8. Believing that you are an expert and know the causes of things, and why patients think, feel, or behave as they do. The causes of all psychiatric disorders are unknown. End of discussion. And yet, almost all therapists promote some fraudulent theory about causality. For example, what is the cause of depression?

There are lots of theories, but none has been confirmed, and almost all have been disproven. For example, there is no evidence whatsoever that depression results from a “chemical imbalance in the brain,” or from “anger turned inward,” and so forth. Those are just theories that someone made up.

I simply tell my patients that we don’t yet know the causes, but have really terrific treatment tools now for rapid recovery. That’s more than enough for the people I treat!

9. Confusing the process of therapy with a good outcome. For example, as a therapist, you could be doing really great job of listening, and give yourself high marks as a therapist because you believe in the importance of empathy, even though your patient is not improving.

Therapists have all kinds of things they’ve been trained to do, like hypnosis, or EMDR, or cognitive therapy, exposure therapy, or meditation, or an exploration of childhood traumas, or whatever it is you do and believe in. But if you’re not seeing rapid and dramatic recovery in your depressed and anxious patients, as documented with session by session testing, you’re not really “helping.”

10. Believing that insight will lead to change. This has only happened once in my career! It was a woman who discovered that she thought she always had to be submissive servant in intimate relationships. Not surprisingly, she always felt burned out and broke up with her partners after a while. She said that the discovery of this pattern when we did the Interpersonal Downward Arrow Technique during our first and only session transformed her life.

But usually, much more will be required. That’s why I have developed 50 methods to help patients change the way they think, feel, and behave. Correction—I have recently developed 51 additional powerful techniques, so now we have 101 ways to untwist your thinking so you can enjoy greater happiness, intimacy, and productivity!

Now, here’s the 60 thousand dollar question. Can therapists learn to stop making these errors? In most cases, the answer is NO! It’s not so much a problem with intelligence or aptitude, although those are important factors, but it has to do with motivation. Many therapists simply do not want to change, and are committed to what they’re already doing, in much the same way that people are committed to their religious beliefs, which they are unwilling to challenge.

That’s why it is so much easier to train young therapists, whose minds are still open, as well as lay people who do not have so much prior “training” they have to overcome.

Well, that’s my cynical side coming out, and I apologize! Still, I think I’m right for the most part.

Hey, if you liked my rant, I have at least five more common therapeutic errors on my list, so let Fabrice and me know if you’d like to hear about therapist errors in a future podcast. In addition, if you’d like to add to our list of therapist errors, let us know what your “favorite” (or most annoying) therapist error is!

Thanks!

david

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Dr. Fabrice Nye currently practices in Redwood City, California and also works with individuals throughout the world via teletherapy (although not across U.S. state lines). You can reach him at fabrice@life.net. You can reach Dr. Burns at david@feelinggood.com. If you like our jingle music and would like to support the composer Brett Van Donsel, you may download it here.

016: Ask David — How can I cope with a complainer? How can I help a loved one who is depressed?

In this episode, David and Fabrice bring the Five Secrets of Effective Communication to life, based on a question submitted by two listeners: How can you help a depressed friend or family member? You may be surprised to discover that the attempt to “help” is rarely effective, and may even make the problem worse. In contrast, the refusal to help is nearly always helpful. But to understand that paradox, you’ll have to give a listen to this fascinating edition of “Ask David!”

David and Fabrice also address a related problem nearly all of us confront from time to time: How do you deal with a friend who is a relentless whiner and complainer? When you try to help them or suggest a solution to the problem, they just say, “That won’t work” and keep complaining. You end up feeling frustrated and annoyed, because the other person just won’t listen! David and Fabrice illustrate a shockingly easy and incredibly effective solution to this problem.

Finally, David discusses some disturbing recent research indicating that the ability of therapists—as well as friends or family members—to know how suicidal someone is, is extremely poor. David and Fabrice explain how to assess how suicidal someone actually is, and what to do if you discover that he or she really is at risk of a suicide attempt.

The Ten Worst Errors Therapists Make–and How to Avoid Them

The Ten Worst Errors Therapists Make–and How to Avoid Them

The Ten Worst Errors Therapists Make–and How to Avoid Them*

©2012 by David D. Burns, MD

Do not copy, publish or reproduce without the written permission of Dr. Burns.

Really good therapy may tend to go against human nature to a certain extent. Unfortunately, therapists keep gravitating toward familiar approaches that are comfortable but ineffective. I have created a list of the ten most common errors therapists make, with the solutions I have proposed for each error. In today’s blog, I will focus on the first of these errors.

Error #1. The Failure to Measure

The great majority of therapists want to work “intuitively,” without quantitative assessment of changes in symptoms each session, and without a quantitative assessment of the quality of the therapeutic alliance. This failure to measure results from the belief that we “know” fairly accurately how our patients are thinking and feeling, based on our training as well as our own feelings and perceptions during the session.

My research and clinical experience have indicated that this belief may be misguided and, in some cases, even dangerous. Therapists’ perceptions of how their patients feel tend to be inaccurate. In other words, your patient could be enraged, and yet you may believe that she or he is not at all angry. Or your patient could have significant negative feelings about you as well as the treatment you are offering, but you may be convinced that you have developed warmth and understanding with that patient. Or, your patient could be planning a suicide attempt within the next couple days, but you may think that he or she is making good progress and feeling a lot better.

Here’s my solution to this problem: My colleagues and I require all patients to complete the Brief Mood Survey (BMS) in the waiting room immediately before each sessions begins, indicating how they feel right now. The BMS includes brief, highly accurate scales that measure depression severity, suicidal urges, anxiety, anger, relationship problems, and positive feelings such as joy, self-esteem, and productivity. It only takes about one minute to complete the BMS.

The patient hands the BMS to the therapist at the start of the session, and the therapist will instantly know exactly how the patient is feeling. The therapist records the scores on a flow sheet in the chart—this takes less than 15 seconds, and a glance will show the therapist exactly how much, or how little, the patient has been progressing since the first session. The therapist also knows exactly how disturbed the patient is feeling right now, at the start of the session, so any serious problems can be addressed.

After the session is over, the patient completes the BMS once again in the waiting room, indicating how she or he feels right now. The patient also rates the therapist on warmth, empathy, helpfulness, and other therapy process dimensions, using extremely sensitive scales, and writes down what he or she liked the least, and the most, about the session. It takes the patient about two minutes to complete the end-of-session assessments. The patient leaves these end-of-session assessments in the therapist’s box before going home.

You can review this information right away, when the session is still fresh in mind. It is like having the world’s greatest supervisor providing specific and accurate feedback at the end of every single therapy session. You will discover exactly how effective you were (or weren’t), and how much your patient improved (or failed to improve) during the session. If you are courageous, this information has the potential to transform your clinical work. However, humility will be required, because the information will often be disturbing to you.

In the Bible, there is mention of the “unforgiveable sin.” Theologians have debated about what this sin might be. I have to confess that I don’t know the answer, but I do believe there is an “unforgiveable sin” that therapists make—and that is the failure to measure. I am convinced that it is impossible to do world-class therapy without measuring at each session. I also believe that the failure to measure reflects a kind of therapist arrogance, or narcissism—the belief that we are “experts” and that our own perceptions of how patient feel (or feel about us) are somehow more accurate than the patient’s perceptions of how they actually do feel. In most cases, nothing could be further from the truth.

Some therapists resist the use of the assessment scales, arguing that patients won’t be honest in the way they fill them out, and will simply tell therapists what they think the therapist wants to hear. Once again, nothing could be further from the truth. When my students (psychiatric and psychology graduate students) use the assessment scales initially in the clinical work, most get failing grades from nearly every patient at nearly every session. So their patients are NOT telling them what they want to hear—they are telling them what they DON’T want to hear!

How about seasoned clinicians like yourself? Unfortunately, your experience will probably be similar. Initially, most seasoned clinicians receive failing grades on the therapeutic empathy and therapy helpfulness scales from almost every patient as well. This can be a huge blow to the ego, and it is one of the reasons that many clinicians refuse to use the scales. They can’t stand the heat.

But there is a silver halo around this cloud. Most students and community clinicians who use the scales with every patient at every session, and who do some Empathy Training using methods I’ve developed, report that within a few weeks, they receive perfect scores 80% of the time, rather than failing scores nearly 100% of the time. So there is hope for a remarkable transformation in your clinical skills—if you have the courage to take this huge step!

Thanks for listening. David Burns, MD