Why Therapy Often Sucks

Therapy often sucks. Therapy Often Sucks

Therapists, while they may have fancy credentials, often do not take the time to become expert at any particular technique. The result is they slosh around with you a little bit in a number of unfocused ways, and you go noplace, slowly.

Therapy Is a Skill Set

Therapy does not differ from other skill sets. You can go to a tennis coach, or you can go to a good tennis coach. You can also go to a fantastic tennis coach. Tennis coaches range in their skill levels, as to other kinds of teachers such as music instructors, yoga teachers, and so on. One thing that really great teachers and coaches have in common is that they have invested the time and energy to master a particular approach to teaching, and that that approach is actually effective.

Systems of Psychotherapy Really Differ

Psychotherapy systems range widely in terms of their level of ambition and scope, their complexity and sophistication, their degree of scientific evidence base, and their degree of rootedness in an ongoing tradition. One way to assess these aspects of therapies is to use a Google or another search engine, or Wikipedia, to learn more about the therapy you are considering getting. Has it been around awhile? Do scientific studies support its use? If so, how many, and how large are these studies? Have newspaper articles been written about it that describe how it is different and new? Or, in the case of older therapies, is there a rich and diverse set of books and other resources available about it?

One not-so-good sign would be that there are only a couple of books and no scientific studies associated with a form of therapy. This would mean it’s basically someone’s pet project and they are experimenting on you, often backed by an enthusiastic, small group of followers who are “true believers” in something that has little scientific support behind it.

Another not-wonderful sign is that a therapist calls themselves “eclectic” or fails to define their therapy approach at all. These can be signs that they have not invested the time and energy to master any particular form of therapy, and you might be better off talking to your Aunt or a friend. Better still, find a good therapist who has done her/his homework and put in their time and sweat.

Relationship With Your Therapist Is Important

Finally, it’s worth recalling that the single best predictor of outcome in therapy is the quality of the therapeutic “alliance,” or relationship between client and therapist. If you feel good about your therapist, that’s likely to predict a better outcome of therapy. Ideally you have both a therapist with expertise in an effective form of therapy, some degree of specialization in your problem area, and you have a good feeling about them interpersonally. When all three of those are in place, and you yourself are ready to do some hard work, you have a great chance at making progress in therapy.

So, have you found therapy to be unhelpful in the past?

Do you have some preconceived notions about therapy in general?

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Joseph Rhinewine, PhD. People collaborate with me to live life fully: with principle, passion and vigor. My expertise is providing and teaching Acceptance and Commitment Therapy (ACT), an evidence-based, experiential and relational behavior therapy. I also apply Acceptance and Commitment processes to coaching those who wish to take their lives to a new level.

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  • Chris

    Good article, had to respond. What I have found is that my previous therapists (I have had a few, dealing with the VA they seem to shuffle around a lot, I’m a combat vet) never did a thorough bio-psycho-social assessment to begin with. I am now a therapist myself (MSW) with the VA.

    A client I am treating and recently diagnosed with PTSD told me he has been working with a private therapist for 2 years (very expensive he says), and when he told her he is a Vietnam vet and was recently diagnosed with PTSD she told him “So that’s it! Thats what was lying underneath everything!” She did not know he was a Vietnam veteran, because he never thought to tell her, and she never asked. Crazy.

    Personally, my least favorite therapists were psychologists. They never seemed to understand the whole “relationship” thing and I often felt like some exotic crippled insect. I work from a CBT, developmental, systemic, psycho-dynamic perspective with an “expertise” in building/sustaining the relationship. All in all, different therapeutic modalities are like the difference between Advil and Tylenol. Its the relationship that heals.

  • Thanks for your comments Chris. I also have found that a thorough assessment is crucial and all-too-rare in current mental health “care”. I worked in the VA system some, but mostly as a research assistant or student. That’s a whole ‘nother world!

    Your story about your client with PTSD is typical. Why do an assessment and diagnosis when you can just plow forward with “therapy”? Further, why even get trained in diagnosis when “the DSM is crap anyway”? Well, the DSM system may not be so good, but a therapist had better have SOME system of diagnosis, and DSM is way, way better than nothing.

    A couple words regarding two distinctions. First, the distinction among different fields (Phd, MSW, etc). I think research shows that there is not much difference in terms of their skill in therapy. Psychologists may tend to err on the side of academic viewpoint “oh gee, what an interesting SPECIMEN my client is!” whilst MSWs may sometimes err on the side of becoming more of an advocate and, well, social worker. I know which I’d prefer — I’d prefer the advocate any day of the week and twice on Sunday! But, I actually had wonderful PhD therapists myself, and some wonderful mentors. So, of course the generalizations are not likely to be too useful. The research suggests it is experience, not which degree, that matters the most.

    Second, regarding differences between therapies, I think the research is clearly in support of what you say–the therapeutic relationship is the single most important predictor of outcome. Also, there is some evidence that for certain problems, certain therapies are more likely to be helpful than others IF AND ONLY IF we assume a good working alliance between therapist and client. So, assuming great working alliances across the board, you’re probably going to get more out of Exposure and Response Prevention for OCD on average across clients than you are, say, out of Rogerian Client-Centered therapy, or even Beck’s Cognitive Therapy or some form of psychoanalysis. That’s what the research suggests. So I would not completely agree with “Advil vs Tylenol” in all cases, but I think there is more truth to that than most of us would like to admit.

    I think it was Carl Rodgers who said, “First, be a human being.” And I think it was John Stewart who says, “Be a f*cking HUMAN!!” 😉

    Thanks again Chris, great to get the comments of a therapist who has, like myself, been a patient.


  • mizzbelle

    Therapy is a contrived, authoritarian relationship promising to delivery authenticity and more autonomy. What could go wrong?

    • Ha! Funny and true. Therapy was called by someone, can’t recall who, “The Impossible Profession.” Might be an overstatement, but certainly worth being keenly aware of the inherent contradictions in the model.

  • Innominate

    Dr. Rhinewine,

    I’ve read a few of your articles, as well as some of your responses to other people’s posts, and I’ve liked your thoughts on several matters.

    Perhaps this is the wrong venue to ask this question, but I must admit that it feels like an appropriate query following this particular article, so I would appreciate your thoughts on the matter: as someone who finds that they are inherently incapable of trusting the mechanisms and machinations which seem to propel psychotherapy*, yet also finds that they’re increasingly unable to rationalize living with the way things are, what would you advise as a reasonable solution to this quandary?


    *To provide a quick bit of background info, I was ‘treated’ for seven months by a psychologist (whom I picked specifically because of a past instance where a GP had essentially left me marooned on a daily 150mg of Venlafaxine…something which still makes me bristle when I think about it, but I assumed [ha ha] that it might be more beneficial for me to work with someone who couldn’t put me on drugs rather than going through the unique challenge of telling a doctor that the drug you were given makes you barely functional and having the doctor retort that you “just need to find a good, mentally-stimulating hobby” before increasing your dosage) who seemed to delight in treating me like a case study and whom I found I was unable to trust due to her intermittent interjections about how certain sentiments I expressed, if they meant certain things, could land me in involuntary commitment…I ended up firing this ‘therapist’ after one particularly stressful session.

    • Innominate – Thanks for your comments and question. Certainly it is appropriate to ask, but I confess, it is always difficult to respond with usefulness and integrity to such important and personally specific questions in such a venue. Nonetheless as you point out, having posted what I did, I should certainly give it a try! You write that you are “inherently incapable of trusting the mechanisms and machinations which seem to propel psychotherapy.” What comes to my mind is that you need not be responsible for such trust–I do not think any psychotherapy client should need to trust our methods. That is probably just why the therapeutic relationship itself must build the trust. Those who trust the methods can be easy to work with, or, just as often, are merely pandering and are just as tricky to work with as those who do not trust the methods. Good work is not based upon an unearned trust in methods that are, at best, our current attempts at understanding the almost unfathomable Human condition and our role as Humans in perpetuating suffering within that condition. Rather, it is based firstly upon an EARNED trust between two individuals, a therapist and a client, and only secondly upon the therapist’s practiced skills using said current scientific understanding of the Human condition etc.

      So. With many words, I think what I am driving at is, what I have to say to you and others who have had this sort of problem is, please carry on and interview therapists — probably in only a single session, or two or three at most — and decide if that is the right person for you before continuing and investing in the work. I welcome this of my clients. I try never to take it personally when people “shop” this way for therapists. The research strongly supports that the goodness-of-fit between therapist and client is of terrific importance to the outcome of therapy. Trust your feelings about the therapist. I hope I don’t sound too Obi-Wan-Kenobi-ish about it. There’s good science to back that statement up, as well as my own experience. We must first be Human, second be therapist-and-client. A good Human connection is the first thing. Although my article is about technique and that some therapists have little, really, the last part of the article is the most important. I could easily have turned it inside out and made the last part the key point. And, perhaps I should have done. Good luck to you; persevere and I am confident you can find someone with whom you can do good work. I have too many superb collegaues — for all my griping and sniping — for that not to occur eventually.

      • Innominate

        Dr. Rhinewine,

        I appreciate you taking the time to offer your thoughts on this matter. I honestly don’t know if I can sever myself from my cynical views of psychoanalysis long enough to ever contend with the therapeutic process again (especially in regard to a potential therapist earning my trust), but if I ever manage it, I will keep your advice in mind.

        Thank you again.