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Good Therapy, Bad Therapy (Maybe Part I)
I’ve had a bunch of both, and therefore I feel fairly qualified to say a few things about them, though I’m not going to try to claim that my experiences will resemble anyone else’s or that the lessons I’ve gleaned from them are universal.
But, you know. Just because my experiences are guaranteed not to be universal doesn’t mean that they might not be helpful to someone else.
So here goes:
- There’s therapy that’s actually going to fix things on a long-term basis, and then there’s therapy that’s basically Field Medicine — trying to keep you in one piece so it’s possible to get back out there and fight another day. Or another hour, or week, or whatever.
They’re very different things: which is to say that they might look exactly alike, and involve the same methods and techniques, but in the long run, they play roles as disparate as military field medicine and civilian obstetrics.
My first therapist, who was very gifted and who I adored, was stuck in the unenviable position of practicing Field Medicine Therapy. Maybe she couldn’t get me off the battlefield, so to speak, but she kept me patched up well enough to keep me going during that time. That was important work, back then.
When you’re stuck in a high-stress situation but are lucky enough to have good therapy, it often functions as Field Medicine Therapy. That means you might still need therapy (maybe totally different therapy) afterwards, and that’s okay.
Then again, you might not, and that’s okay, too.
- Some of the worst therapy I’ve had has been provided by PhDs (which doesn’t mean all PhDs are bad therapists; read on). Also some of the best.
Some of the best therapy I’ve had has been provided by people with Master’s degrees — and, in particular, by my current therapist, a great lady with a Master’s in Education (which is actually a reasonably common therapy credential in Kentucky due to our state licensure system).
It’s worth remembering that a PhD, at least in the United States, is a research-based, academically-oriented degree, and few US PhD programs in Psychology are actually aimed at producing therapists. Many are aimed at producing clinicians who are also academics, but not necessarily clinicians who practice psychotherapy.
PsyD programs, meanwhile, tend to be more practice oriented, but they also aren’t necessarily geared towards producing better therapists. Unfortunately, I don’t know a heck of a lot else about them, except the fact that they’re generally less oriented towards an academic career track and more towards a practice-oriented, clinical one.
So a PhD-level therapist isn’t necessarily going to be a better therapist than a Master’s-level therapist — which isn’t to say that PhD- or PsyD-credentialed practitioners can’t be awesome.
Just that you’re not getting short-changed if your therapist doesn’t hold a doctorate of some kind.
- Some of the worst therapy I’ve had has been provided by very good people with the very best of intentions.
I was really pretty angry for a long time at some of the practitioners who were responsible for my care when I was in high school.
It’s been long enough now that I’m comfortable stepping back and recognizing that, while at least one of them was a complete dick (who was asked to resign from her position after an episode of particular dickishness), most were good people doing the best they could with what they had. They were also unwittingly practicing field medicine; sending me back every time I walked out the door into a situation that, at the time, was pretty harmful (though the worst part was behind me by then and, ironically, took place in a gap between therapists).
That didn’t make it easier to cope with at the time, but it does make it easier to forgive them now.
As does, I suppose, knowing that whatever damage might have been done by therapeutic decisions that led to unforeseen consequences (hellooooo, meds), I do to a great extent owe my life to the people who did their best to take care of me when I was in high school.
But it was still terrible therapy … and they were still good people.
- The best therapist for you might not be the best therapist for someone else.
The best therapy for you might not be the best therapy for someone else.
Heck, sometimes, it may not even be possible to delineate what’s therapeutic about the best therapy: while my current, brilliant therapist is influenced by the classical talk-therapy school, including the practical (but not the weird theoretical) ideas of Freud, I’d describe her style as eclectic.
Often, we just Talk About Stuff — but somehow the Stuff we talk about is real stuff even when I manage to walk into a session manic as a crack-addled ferret and convinced that Everything Is Just Fine.
And, while I couldn’t outline exactly how she’s done it, D. has operated as a mirror of fresh insight in a way that has been transformative for me in a way that no other therapist has (in part because even my best prior therapist, who I adored, was practicing field medicine).
And this is a lady with a Master’s in Education, so once again, if you’re worried about credentials … sometimes the best credential is a jillion years of experience and a recommendation from someone you, the patient, trust.
- Like school, therapy is something you pay for.
That means that if your therapy isn’t working for you, you’re totally allowed to speak up about it.
And if your therapist is a jerk, you’re allowed to fire him (or her; jerky therapists come in all sexes, sizes, etc). You’re even allowed to fire your therapist (and, one hopes, find a new one) if your therapist just isn’t a good fit for you. Sometimes that happens.
True, as with school, therapy is something that isn’t going to work as well if you don’t do your end of things.
That said, as with school, if you’re not doing your end of things, you might be over-faced — and it’s okay to say, “I’m not ready for this level yet; I need to step back to therapy without fractions and work on the basics some more.” I have totally done that, and my therapist totally did not kill me.
Also as with school, you’re not doing your end of things just because, you’re screwing yourself outta money! Why you wanna do that?!
But if you’re doing what you can and it’s not working, it’s okay to speak up.
- Therapy doesn’t have to be forever, but it doesn’t have to not be, either.
It’s okay to stop, then start up again, or cut back, then step it up again. It’s a service.
If it helps, you can compare it to physical therapy: you might start physical therapy to address some kind of longstanding muscle imbalance, get that sorted over the course of therapy, be fine for a while, then end up with an injury (maybe even one that causes the old problem to re-surface) and need another course of therapy.
That doesn’t mean that the original course of therapy didn’t work, or that you don’t deserve the new course of therapy.
Likewise, sometimes you might get assigned a course of physical therapy and not actually do the exercises for whatever reason (which as TOTALLY NEVER HAPPENED TO ME, okay? I am the BEST PHYSICAL THERAPY PATIENT. …Um, is my husband looking?). So that therapy might not work as well as it could have, and you might need to try again later. Your physical therapist might be all, “Did you do your exercises?” … but she’s not actually going to kill you, and if she’s really good at her job, she probably won’t guilt-trip you, either.
Good psychotherapists kind of work the same way. They don’t guilt trip you about not doing those million leg lifts, or whatever their psychotherapeutic equivalent is, between back when you finished your last course of therapy and now. They just help you get down to work.
- Lastly, good therapy is not always easy to find.
People can be really judgmental if you’re not in therapy and maybe you should be.
Those people are jerks, and you can tell them I said so.
Even though I just said bad therapy was nonetheless partly responsible for saving my life, bad therapy can also be worse than no therapy (you could make a physical therapy analogy here, too: a bad physical therapist, especially one who’s heavily invested in some trendy new modality, can seriously hurt you and leave you needing way more physical therapy than you did when you started).
Sometimes you just kind of have to do what you can and forego therapy until you find a good therapist.
And that’s okay, too.
You gotta do what you gotta do.
So that’s all for now.
Again, your mileage may vary (and, in fact, it may vary enormously, which is also totally okay) … but I hope some of it might be useful to somebody, somewhere.
In Defense of Anecdotes
Ages ago, I found myself debating the value of anecdotes with a friend.
He argued that anecdotes should never be used because they can just as easily represent outliers as norms; I argued that they were extremely valuable as vehicles — people remember stories better than they remember reams of data.
I now realize that we were arguing at cross-purposes. He was arguing that anecdotal evidence should not be used to confirm or deny research hypotheses (a position on which we actually agree); I was arguing that anecdotes have a place in explaining the findings of research to people who don’t necessarily know a great deal about statistics and levels of measurement and all that jazz. I have no idea how he feels about that. I’ll have to ask the next time I see him.
It is true that individual anecdotes can’t tell us much about how the world actually works: if we only hear one story, we can’t glean from that single story whether that story is typical or atypical. Therefore, we can’t base statistical analyses on small samples of individual anecdotes, and we can’t make sound statements about causality or even, really, about correlations based on small samples of individual anecdotes.
When we try to ascribe causality based on anecdotes, we run into problems: for example, a book detailing how the use of Applied Behavioral Analysis (ABA) led to one child’s “recovery” from autistic spectrum disorder (ASD) does not actually mean that ABA can produce the same results for all, or even most, kids (or adults) with ASD. In fact, most of the time, it doesn’t (this isn’t to say that ABA isn’t a valuable tool; just that it’s not usually a miracle cure) — but reading one or two books recounting the story of one or two kids who “recovered” can lead to the impression that ASD is “curable” in most or all cases and “should” be cured using ABA(1).
If, as a parent or helping professional, you read only that book, or those two books, and you decide that they represent a typical view of the world, you’ll have based your entire understanding — your entire statistical analysis, informal though it may be — on an anomaly, but you won’t necessarily know it.
A research paper, meanwhile, that looks at a sample of a couple of thousand folks with ASD and examines outcomes of their experiences with ABA will undoubtedly produce a different picture of the efficacy of ABA and the “curability” of ASD. From such a paper, we’ll be able to get a better sense of the relationship between ASD and ABA: does ABA lead to improved outcomes(2) for people with ASD? Such a study will, ideally, also answer a few other important questions:
- How often do improved outcomes occur?
- How much improvement are we talking about?
- How are we even defining “improved outcomes?”
If a study is sufficiently well-designed and well-controlled, we might even be able to draw some inferences about causality(3).
Unfortunately, the results of the research in question will most likely be published only in academic journals and textbooks, only a few of which will actually be accessible to the general public, only a few of whom will actually have the knowledge to interpret the results(4).
Thus, the likelihood that the average parent of a young child with ASD will be able to lay hands directly on sound research is much smaller than the likelihood that the same parent will be able to read a popular, anecdotal book.
This is where the power of the anecdote comes in handy: as researchers and as helping professionals, we have access to data that can help us to convey information to a broader audience — and we can select anecdotes that do reflect statistical realities. We also, incidentally, are often people who are interested in stories: research, to some extent, is about figuring out the “who (even if the who in question is, for example, a chemical messenger or an invisible physical force), what, when, where, why, and how” of things. In short, results can be translated into anecdotes.
Those anecdotes, in turn, can help people feel connected to the subject at hand, which is immensely important. A bunch of dry statistics about ABA and ASD won’t really influence how most people feel about whether ABA is an important and useful intervention or not; a true story, on the other hand, will — but with that power comes responsibility. When they’re used to reflect the realities revealed by careful research, anecdotes should be told in a way that reflects those realities; a way that reflects a typical (that is, an average) experience(5).
We’ve probably all seen television ads for weight-loss products with “RESULTS NOT TYPICAL” emblazoned across the bottom of the screen. Unfortunately, biographical and autobiographical books recounting anecdotes about recovery from neurological and psychological conditions aren’t required to carry those labels.
We probably can’t (and, for various reasons, probably shouldn’t) force them to — but we can find ways to tell harness the power of anecdotes to present results that are typical, so potential health-care consumers have a better shot at making informed choices.
Notes
- I don’t agree with either of these assertions, by the way; nor do I agree that the ability to function just like a neurotypical person in the neurotypical world is necessarily a desirable or reasonable goal. For some of us, it might be. For others, it’s not.
- “Improved outcomes” as operationally defined by the study — I guess operational definitions are a subject for another post.
- though this is notoriously hard to do in the field of psychology as a whole due to difficulties both with ethics (we’re not generally allowed to dissect people after applying a drug intervention to see what happened to their brains, nor can we keep them isolated in stimulus-free environments, etc.) and the complexity of human subjects (even if we could keep humans isolated in stimulus-free environments, that alone could become a confound, etc).
- In short, this is a skill that’s usually taught at the university level, and then primarily to students in disciplines with strong research components. In the US, that amounts to a fairly small subset of the general populace.
- I think it’s okay to mention the outliers as well — those atypical results that look so great, or so awful — but we must do so with the knowledge that, on the whole, most of us expect our individual case to be an exception, and moreover, to be a good exception: one with results better rather than worse, than is typical. In short, we need to present outliers with several grains of salt, and we need to balance the better-than-typical outcomes by also presenting the worse-than-typical ones.
danseur ignoble 