123: Ten MORE Errors Therapists Make (Part 1)

I was concerned that our recent "Ten Most Common Therapist Errors" show might antagonize people, but we got quite a lot of positive and encouraging feedback from listeners, which was surprising to me. As a result, Fabrice and I decided to take a chance and publish two more shows on common therapist errors this week and next week. We hope you like these shows!

Make sure you let us know what you think, and let me apologize in advance if I come across as annoying or overly cynical. All of the errors I describe are correctable; the goal is to improve the treatment of individuals struggling with depression, anxiety, troubled relationships, or habits and addictions. Thanks!

Here are the five errors discussed in today's show.

1. Failure to hold patients accountable. Example, the therapist may let the depressed patient slip by without doing psychotherapy homework, since the patient insists he or she doesn't have enough time or motivation to do the homework; or the therapist may agree to treatment an anxious patient without using exposure, since the patient may resist exposure; or a patient may treat someone with a relationship conflict without exploring the patient's role in the problem, and so forth.

David argues that this rarely or never leads to significant change, much less recovery. However, many therapists, and perhaps most, get seduced into this error for a variety of reasons.

2, The "corrective emotional experience." This is the belief that the patient's long-term relationship with the therapist will be sufficient for growth and recovery, without having to do any psychotherapy homework or be accountable. Therapist may imagine himself or herself as the loving and nurturing parent the patient never had.

David argues that this caters to the therapist's ego and feeds into what the patient wants as well—a long-term relationship built on schmoozing.

But does it lead to recovery?

Here's David's short answer: Nope! Warmth, empathy, and trust are necessary ingredients for good therapy, but they are simply not sufficient. Your patient may think you're the most wonderful and supportive listener in the world, but that will rarely or never lead to recovery from depression, an anxiety disorder, or an addiction, and it will not lead to the skills to heal troubled relationships, either.

3. Responding defensively to patient criticisms. David argues that therapists almost always react defensively to criticisms by patients, such "you don't' get me," or "you aren't helping," or "you don't really care about me." He describes an interesting five-year study of psychoanalysts in Atlanta, Georgia, sponsored by the National Institute of Mental Health (NIMH), to find out how the analysts responded to patient criticisms. You may find the results surprising!

He gives an example of defensive responding during a workshop he conducted at a hospital in Pennsylvania. Therapists can learn to correct this error with lots of practice with the Five Secrets of Effective Communication, but this requires several things:

• Using the Patient's Evaluation of Therapy Session after each session so can quickly pinpoint empathy / relationship failures.
• Lots of practice with the Five Secrets.
• Humility, and the willingness to see the world through the eyes of the patient. This requires the "Great Death" of the therapist's ego!

4. Joining a school of therapy and treating everything with the same method or approach. Can you imagine what it would be like if medicine was organized like this, with "schools of therapy," like the "penicillin school"? David apologetically argues that the abolition of all schools of therapy would be a good thing. Fabrice disagrees, and argues that the treatment of psychological problems is inherently different from the treatment of medical disorders.

Let us know what YOU think!

5. Confirmation paradox. I (David) majored in the philosophy of science in college, and this was one of the first topics, and it definitely applies to our thinking about the causes of emotional problems. I'll try to make it really simple and understandable.

Here's the essence of this error. If I have a theory that predicts the patient's behavior you may conclude that your theory is correct. But this logic can be very misleading. Here's a general science example

• Your theory: the sun circles around the earth.
• Your prediction: if my theory is true, the sun will come up in the east each morning and set in the west each evening.
• Your observation: the sun DOES come up in the east and set in the west, exactly as predicted.
• Your erroneous conclusion: the sun circles around the earth.

Now let's consider a psychotherapy example. Many therapists believe that perfectionism and insecurity result from growing up with parents who emphasized hard work and high standards as a precondition for being loved. Now let's assume that you have a perfectionistic and insecure patient who remembers feeling like s/he wasn't good enough when growing up. So, you conclude that the patient's interaction with demanding parents caused the perfectionism and insecurity.

But the perfectionism and insecurity may not have resulted from any childhood experiences or interactions with parents. It may have been strongly influenced by genetic factors, or social / environmental pressures.

We can put this in the same framework as the example about the sun:

• Your theory: Perfectionism and insecurity result from growing up in unloving families that emphasized high standards and achievement rather than unconditional love and nurture.
• Your prediction: Insecure, perfectionistic patients will report childhood experiences with unloving parents who pushed them to work harder, etc.
• Your observation: Your insecure, perfectionistic patients DO describe their parents as demanding and lacking in love and support.
• Your erroneous conclusions: The patient's childhood experiences caused the perfectionism. 2. The patient will have to "work through" these childhood experiences if s/he wants to overcome the feelings of perfectionism and insecurity.