For the third week of class this semester, my students read a story about a patient of mine that died. Bobby’s severe drug use had damaged his brain and he was painfully aware that he was diminished. At some point each session, Bobby would ask “When will my brain heal?”
I always refused to lie. I told him that he may have done permanent damage but we would never really know until he had a few years of total abstinence from substances.
That exchange shocked my students. They were uncomfortable with the concept of delivering bad news. “You didn’t soften it,” one said.
“That would be bad therapy,” I responded.
Another student softly muttered, “I need to get a new therapist.” A few others nodded. Many of my students get bad therapy. Between their personal experiences and, at times, woeful supervision, they are being trained this way.
Bad Therapy often looks like:
- Premature reassurance
- Incorrect validation
- Ideological Collusion
- Passing over key moments
- Avoiding core questions
- Avoidance due to clinician discomfort
- Diagnostic inflation
- Failure to ask foundational questions
- Failure to review records
- Failure to reassess diagnosis
- Failure to recognize origin patterns
- Forced insight and change too quickly
Some people are in therapy for three years and have not moved an inch.
A 28-year-old woman was anxious about a job she applied for. Her therapist responded, “You’ll get the job. They’d be crazy not to hire you.” The therapist promised an outcome that was actually uncertain. A temporary sense of relief. This is premature reassurance.
“If you get the job, good for you. If you don’t it, we’ll discuss your next moves and apply for some other jobs.”
A 33-year-old woman often complained in therapy about her mom, boss, co-workers, friends and last three boyfriends. The therapist agrees with each complaint. This is incorrect validation.
The therapist never names the one thing they all have in common.
A right-wing client goes to see a right-wing therapist. The client complains about liberals, immigration, crimes and pronouns. The therapist agrees that America is going down the toilet.
A progressive client goes to see a progressive therapist. The client complains about MAGA, racism and the cost of housing. The therapist agrees that America may no longer be a Democracy. This is ideological collusion, where therapy becomes an echo chamber. Agreement replaces agency.
A group of high school athletes meet with a school counselor to talk about managing their time. One mentions that he is “afraid of my Dad.” The clinician doesn’t stop to address it. This is passing over a key moment.
A couple goes to couples therapy every week for nine months. They argue both in and out of session. At no point did the clinician ask, “Do you want to stay married?” The man didn’t. Nine months had been wasted. This is avoiding core questions.
Well over a decade ago, I listened as a psychologist did a case presentation on a 26-year-old lesbian who had recently left the Navy and was new to Rutgers. She was having relationship problems. I asked her how often the client and her partner were having sex. “I didn’t ask about that,” the psychologist answered. I told her that it was an important question. This is avoidance due to clinician discomfort.
A 23-year-old man goes to a therapist to deal with the death of his older brother several years earlier. The therapist never asks, “How did you find out?” This is one of the most important questions when dealing with grief early on, as finding the body is different than getting a text message which is different than someone calling you on the phone and telling you directly. This is entry trauma ignored, which is often avoidance due to clinician discomfort.
Diagnostic Errors
An 18-year-old female walked into my office at Rutgers in the fall of 2009. “I’m bi-polar and have borderline personality disorder. I have anxiety, depression, ADHD and PTSD. I am in recovery from alcohol, marijuana and hallucinogens.”
“Let’s back up a minute. Tell me your name and where you are from,” I countered.
She had walked in with seven diagnoses. Her identity was wrapped around pathology. She later told me she felt irrevocably broken. This is diagnostic inflation.
I was hired by a program in New York City to help about a half dozen clinicians improve their skills and work on their case presentations. After the first one presented a case involving insomnia, I asked, “How long has this been going on?” He couldn’t answer. Another clinician presented on about an abusive relationship. “What do her friends think?” She couldn’t answer. A third clinician discussed a client’s overly anxious responses. “Where did they grow up? Are her parents alive?” They couldn’t answer. These were blatant failures to ask foundational questions.
A parent of a 30-year-old man at a treatment program that I was consulting with in Pennsylvania contacted me with concerns about her son. Based on her description, it was clear that he had schizophrenia. Years of records were available, but the treating clinician had never obtained them. They only had obtained the records from the referring detox. Even in other areas of medicine, there is sometimes a failure to review prior records.
When I was in the Army, a 25-year-old female soldier mistakenly walked into my office. She was being medically discharged from the Army because she had been diagnosed with bi-polar disorder. She had caught her boyfriend in their bed when she came home a day early from training. She broke up with him, packed up her stuff and moved back in with her parents. She had a hard time sleeping for a few days and couldn’t get her mind to stop racing. She went to the emergency room at Hershey Hospital and the doctor diagnosed her with bi-polar disorder. Ridiculous. She wasn’t bi-polar, she was upset from a break up. I reassessed her and she was able to stay in the Army. Therapists take in clients and often just reaffirm diagnoses instead of reassess them. Diagnosis is not a permanent label, but rather an ongoing process. All too often, therapists and other medical professionals fail to reassess diagnoses.
Just before COVID, a 43-year-old cop came to see me. He was miserable at work; so much that his wife wanted him to quit after 18 1/2 years. He only needed to work another one and a half years to get his pension. He had seen a few other therapists and nothing had helped.
“Well,” I told him, “we aren’t quitting this close to retirement.” I went through his background and learned his father was an abusive alcoholic. I told him that I wanted him to go to three Adult Children of Alcoholics (ACOA) meetings in the next month. When he returned, he had gone to 20.
“After the fourth one, I called my younger sister and said, ‘it wasn’t us.'” Dealing with his family of origin issues lowered his stress baseline and he was able to survive his last few years at work. He actually lasted another four years before he retired. This was an example of failure to recognize origin patterns.
In 2010, a 25-year-old male graduate student came to me for help with his anxiety and “bitchy” girlfriend. I recognized his drinking problem within 15 minutes. I told him that I wanted him to attend Early Recovery Group on Tuesdays and check out a few on-campus AA meetings with some other students. He disappeared for six weeks.
I told my supervisor what happened.
“He left because you were forcing him to a place he didn’t want to go. He didn’t see alcohol as problem. He wanted to work on his anxiety and relationship.”
“Those aren’t his primary issues,” I responded.
She calmly smiled. “To him, they are.”
He returned after six weeks and we worked on his anxiety and romantic relationship fights. After 18 weeks, he started to see the connection between those problems and his drinking. My mistake was an example of forced insight and change too quickly.
I have worked with people who took six months to realize what I knew in 15 minutes. That used to feel like wasted time. Now I accept that it sometimes takes people a long time to recognize their problems.
Some people sit in therapy and never move. A bad therapist won’t push or challenge them, point out when their behaviors aren’t matching up with their values and often engages in going-nowhere-validation therapy.