The Trouble with Therapy 1. Clinical Dimensions

by Barbara Dowds

It seems a pity that psychology should have destroyed all our knowledge of human nature.

G.K. Chesterton

Introduction

A number of years ago, when I was enthusing to a fellow-therapist about a book on client experiences of therapy, she retorted impatiently that she wasn’t interested in reading what clients had to say, only theoreticians. This breathtaking arrogance, this belief that it is not necessary to listen to the client, encapsulates why therapy can go wrong. The book in question was One to One by Rosemary Dinnage (1989) and my interest in it lay in my own frustrations as a client and my curiosity about whether I was alone in this. I felt blocked in most of the one-to-one therapy I had tried, despite persisting for a year or more in most cases. I felt I was swimming round in a void, where what I needed was not on offer. This was above all authentic and contactful mutual relating with a little explicit teaching (e.g. it’s about feeling, not intellectualizing). I needed a therapist with intelligence, depth and vision, who was capable of being present herself and able to hear me. I was asking for a fantastic amount, but the reality was that without all of that I was unable to progress. I was suspicious about the many published case studies and anecdotes in theoretical works, all of which demonstrated successful outcomes – often dramatically so. Ironically, two therapeutic relationships with non-psychotherapists, one an acupuncturist and the other an energy worker, did meet my needs: I learned an enormous amount of bodymind and existential awareness and, at last, experienced the nourishment of good contact. In addition, group therapy worked well for me, but is largely unavailable.

Now, Yvonne Bates has edited a book about people damaged by therapy with the plaintive title: Shouldn’t I be Feeling Better by Now? This is a collection of testimonies and critiques from clients, summaries of the issues by Bates and, finally, a section on “Working Towards Solutions” in which 18 eminent therapists and client-writers come up with suggestions about going forward from here. Bates also expanded on a number of matters in interview with me (for full interview, see links and resources page). There is a dearth of reported client experiences (House 2003: 96), despite the staggering number of lawsuits against psychotherapy (House 2003: 29) in the USA – 10,000 in 1998!  Therefore, Bates has performed an important task in bringing to light some of the routine damage wrought by therapy. It is vital to note that the problems arose not through rogue therapists, but through excessive adherence to theory and insufficient humility in the light of our very limited understanding of therapy in general and transference in particular. As Bates commented: “By and large I think therapists do an excellent job, but the problems with which we are concerned in the book lie in the nature of therapy itself rather than an individual practitioner’s skills” (my italics).

Client stories and Iatrogenic Material

There are major methodological difficulties in all approaches to research into the efficacy of therapy, including the impossibility of objectively separating out the issues brought by the client in the first place from problems generated by the therapy process itself (see House 2003: 103-107). House concludes (p. 125) that “any ‘objective’ empirical research is in principle impossible in this highly peculiar field – in which case subjective, impressionistic data is at least as reliable as any other”.

(a) Transference

The clients who told their stories in Bates’s book have been in a broad range of therapies with a predominance of analytic styles, either in the Freudian or Jungian traditions. All felt they became much more disturbed as a result of their therapy because of the generation of crippling transference or dependence, or because of the negative power of the therapist’s countertransference. In conversation with me, Bates elaborated on the term transference:

“A typical dictionary definition is ‘In psychoanalysis, the process by which emotions and desires originally associated with one person, such as a parent or sibling, are unconsciously shifted to another person, especially to the analyst’.

If I were to define what clients have discussed with me, I would say it is ‘An extremely deep attachment or bonding to a therapist, characterized by overwhelming love, devotion, obsession and desire to possess the therapist. There is a sense of the therapist having the power of life and death over the client, the therapist’s words and opinions feeling like divine truth and a sense of numbness to, and irrelevance of, the client’s life and relationships outside of the therapy room’.

I think there is a fundamental issue in the difference between these two definitions – ‘transference’ as described in the first, official definition, one could argue, is present to a greater or lesser degree in all relationships, whereas the second definition is something that is very peculiar to the therapy situation and may have no connection at all to the first definition. I feel that the official definition is a theory as to the reason for the phenomenon, rather than a description of the phenomenon. An excellent first step in our really understanding it would be for the profession to accept the second definition. That is what happens. When we can be clear about what happens, then we can move on to investigate why it happens, because that might have nothing to do at all with the transferring of feelings from past relationships onto the therapist!

My belief is that ‘transference’ (the unofficial definition) occurs very commonly in all forms of therapy, in some clients mildly and in others strongly. Now, one can speculate as to why this is; if ‘transference’ really is caused by the feelings for a parent or significant caregiver being transferred onto the therapist, then perhaps if that significant caregiver was very withholding and distant, a psychodynamic therapist would recreate that and thus possibly retraumatise her. A client whose significant caregiver was very smothering might do better with a ‘blank screen’ approach but be retraumatised by a more nurturing, affectionate therapist. My wish in editing Shouldn’t I Be Feeling Better By Now? is to take us back to the drawing board, accept that transference is far more common than anyone has wanted to admit, and to work with clients to identify what exactly this phenomenon is and what we can do to make it less painful, humiliating and counterproductive. This phenomenon is far more prevalent and can be far more destructive to the lives of clients and their families than the profession seems willing to admit. I know of several suicides which I am in no doubt were caused by transference, and I know many, many people who will suffer the effects for the rest of their lives”.

(b) Other Iatrogenic Problems

Elsewhere in the Bates book, Anna Sands points to a number of issues not covered by the other clients.  These include: the use in therapy of disempowering and pathologising language; the “dissolving of the adult’s boundary between fantasy and reality” (Bates 2006: 128); the therapist modelling a false self (aloofness, non-responsiveness); and encouraging – even insisting upon – amorality and selfishness (e.g. interpreting the individual’s response to another’s pain as projection). Ann France in the story of her analysis, Consuming Psychotherapy (digested by House in Chapter 7 of Bates), also points to the addictive nature of therapy, the distorted social expectations that accrue, the undermining of the client’s autonomy and the requirement that the client behave inadequately, which may actually create feelings of inadequacy. There is a crazy-making circularity of argument in many strands of psychotherapy, where all disagreement is ‘resistance’ and all present- time interaction is ‘transference’.

One central trouble with therapy arises when its dissection of (supposedly) the client’s unconscious is being done by therapists who are not in touch with their own body process, wherein the unconscious is located. Reich, and implicitly Freud himself, were aware of this early on, but body psychotherapy seems to have got lost in much current practice.  In the absence of the groundedness that comes with body awareness, you enter a mad Alice-in-Wonderland word where anything can mean anything and the lunatics are indeed running the asylum.  Some analysts do to their client’s psyches what Salvador Dali did to his canvasses: fill them with their own lurid projections.

John Rowan (2005: 3-5) identifies three approaches to therapy: the instrumental, the authentic and the transpersonal. The instrumental way involves an I-it relationship, a view of the client as a machine with broken elements and a belief in techniques and cures. The authentic way requires more personal development from the therapist towards body-mind holism and has the aim, not of curing, but of the client (and therapist) moving towards authenticity. In the transpersonal way, the boundaries between therapist and client may fall away and it is necessary for the therapist to have experienced the subtle level of psychospiritual development. Rowan lists Freudian psychoanalysis as well as CBT under the instrumental approaches, and I would argue that it is the use of this I-it relationship when working on the unconscious that generates much of the damage described above. There are undoubtedly many analysts who, because of their own personality, relate in an I-thou manner, but the nature of analytic work in no way precludes – and may even encourage – those with a particular character armour from practising impeccably and yet doing a great deal of harm. It is suggested repeatedly by iatrogenically-damaged clients that therapists haven’t a clue what they are doing, and are particularly at sea when things go wrong. Some of the work described looks like monkeys doing brain surgery with screwdrivers.

Damage associated with most models of therapy

Most readers of Inside Out probably practice, like myself, in a humanistic and integrative manner and may wonder what relevance there is for us in the descriptions of iatrogenic damage wrought by primarily analytic therapy elaborated in Dinnage, House and Bates.  However, four major problems are common to most models of therapy. Many pathologise the client and intensify their perception of what’s wrong with their lives. Even in orientations that focus on an individual’s strengths, the client is still the inadequate supplicant coming for help to the expert. Bates, using the terminology of transactional analysis, says that the client plays the role of child or occasionally adult, but never takes the parent position, where ‘a lot of our sense of self-worth and positive identity is expressed’.

Secondly, Bates (www.therapybreakdown.com) highlights the sociological dimension:

“Almost all forms of therapy are underpinned by the basic assumption that ‘you can’t change the world but you can change yourself to adapt to the world’……If we are living in a society where there is no sense of community, where people are pitted against each other in a dog-eat-dog way, where everything is driven by money and consumerism and the large corporations, where there is no or little time for compassion, friendship, leisure and relaxation, where there has been a demise of religious faith and an existential void replacing it, then is it not natural for the human organism to struggle? Therapy’s role can be seen as focusing on the internal world of an individual and thereby masking and distracting us from the real problem”.

Thirdly, therapy can damage relationships outside the therapy room when it deconstructs them without taking into account the social context – either of childhood experiences or indeed of current relationships – or when the client’s energy becomes so consumed by transference that they fail to attend to their ‘real-life’ relationships.

The central tragedy of the therapy project lies in its inherent paradox: that in getting to know ourselves we lose ourselves. Therapy amplifies detached awareness to such a degree that we lose the possibility of direct experiencing. As part of both our individual development and the evolution of our culture, we have lost what Berman (1981) calls participative consciousness. Most therapy contributes to our separation from this expanded self, though I would like to believe that our resulting alienation can be transcended through transpersonal therapy or ecopsychology.

Damage specific to Humanistic Therapy

Even in humanistic therapy, where we aim towards a non-directive, transparent and I-thou relationship, we cannot afford to be too complacent. First of all, person-centred therapy and counselling frequently suffer from the phenomenon of the bland leading the blind: the core conditions are interpreted as being nice to the client and the primary element of therapist congruence is omitted. As Mearns and Thorne (2007: 114) argue, being nice is a socialized mask and has more to do with relational superficiality than relational depth. This sin of omission may have less devastating consequences than some of the abuses listed by Bates, but can certainly engender hostility, despair or a feeling of being ripped off or not taken seriously. In my experience, such fear, laziness or misunderstanding of person-centred therapy is widespread.  Bates would also like to see a greater awareness of and transparency about the impossibility of non-directiveness amongst client-centred practitioners and training organizations (Bates 2006: 141).  A third problem is that most practitioners of humanistic therapy also claim to be ‘integrative’. What, in reality, does this actually mean?

What is Integrated in Integrative Psychotherapy?

What has crept into humanistic therapy under the guise of integrative approaches? Some of these practices may be wholly incompatible with the person-centred principles that form the relational heart of humanistic practice or with the Reichian or Gestalt principles that comprise its body.

From my own experience with a variety of training organisations, group facilitators, therapists and supervisors, all of whom claim to be humanistic and integrative, there are many who have imported, not just the invaluable developmental theory of psychoanalysis, but also its abusive practices and beliefs. After two days sampling a training institute being held at arm’s length without any engagement from trainers, a refusal to answer legitimate questions and in the vacuum of group analytic practice, I concluded that I had more than enough issues already, particularly round frustration and non-relationship, without the additional avalanche I could see coming from these sadistic (in effect, if not intent) power games. A Freudian would no doubt say that in withholding the very thing I needed, I was being provoked into feeling the feelings. In fact, as body therapists, neurobiologists and behaviourists know all too well, a repeat of the insult simply leads to re-traumatisation unless the repeat is held in a different and healing framework (Rothschild 2000).  The pattern needs to be broken, not reaffirmed. Far from a withholding of contact, it has been subsequent empathic and responsive relationship (e.g. in psychodrama and Gestalt groups and in deeply empathic Winnicottian therapy)Since then I have seen too many graduates of the above and similar regimes, who remain angry, defensive or fearful for years as a direct result of the training, or, on the other hand, survive and ‘flourish’ by the acquisition of an armoured false self. Many of these students have been brainwashed into accepting the insults, and indeed view them as a necessary part of becoming a therapist!  I am all for trainees facing up to their issues, but not for making the problems worse, or adding more.

Some of the other ways in which non-person centred practices have crept into humanistic and integrative psychotherapy and training include: cold, rigid or controlling ways of relating; refusal to engage with or answer questions; highly unequal relationships, e.g. expecting students to expose themselves without the tutor doing likewise; the student/client being blamed (e.g. for transference) while the tutor/therapist refuses to acknowledge any responsibility for their part in the interaction; a general infantilizing demand for compliance; fitting the person to the theory instead of expanding the theory to fit the person; punitive and inflexible practices (e.g. client must pay every week, whether they attend or not – it appears to be the client’s duty to pay the therapist’s mortgage!); the consistent locating of distress within the individual, where sometimes it belongs in the group or the society at large; the narcissistic insistence that everything is about the therapy (e.g. a single cancellation indicates ‘hostility’ or ‘resistance’ rather than the overwhelmingly overcrowded state of your life – which is presumed to narrow down to 1 hour a week, while the remaining 167 hours are irrelevant!); insistence on the therapist’s interpretation, when actually the client is the expert on their own psyche; a denial of common sense; and a refusal to hear, which coming from a figure of authority can lead to feelings of rage or loss of reality, if you haven’t got a strong ego.

These are all problems of a non-transparent, unequal, I-it relationship where the therapist pretends to be a blank screen, believes themselves to be the expert and to have entitlements that the client does not have.  I have had all of the listed experiences – not in psychoanalysis but with practitioners and courses claiming to purvey humanistic/integrative therapy. Psychoanalysis, possibly through not shying away from power issues, has become a powerful force in academia. Its kudos and its very real theoretical muscle shouldn’t blind us to the dangers – and sometimes absurdity – of its practices and to its incompatibility with the I-thou relationship that is central to the authentic way of humanistic therapy. House (2003: 30) maintains that Freud’s primary interest was making sense of people and that he only took to psychoanalysis as a way of earning a living.  He quotes Kurtz as follows: “the narcissistic and psychotic …layers of Freud’s personality entered profoundly into his creation of the psychoanalytic situation and its manifestation in space …every analyst to some degree recreates that office in Berggasse”. We might do better to model ourselves upon people who were primarily practitioners of psychotherapy and capable of healthy relationships.

Towards Solutions

It is not clear just how common iatrogenic damage is in therapy.  Amongst Dinnage’s 20 interviewees and 30 different experiences (several clients moved on from a bad therapist to a better relationship later) of psychoanalytically based psychotherapy, I estimate that half felt the enterprise had been beneficial, more than a quarter were damaged by the experience and less than a quarter seemed untouched by it, neither helped nor diminished, except in their bank accounts. The phenomenon of ‘spontaneous recovery’ (McLeod 2003: 118) informs us that many people get better in the absence of treatment, so the actual effectiveness of therapy is still unclear. Bates (www.therapybreakdown.com) recalled Martin Seligman in an interview in 2004 saying that he had worked through thousands upon thousands of research studies as to the efficacy of therapy and that the average improvement is about 65% as opposed to 50% with a placebo! (Also see Seligman 1995).

Bates and I draw slightly different conclusions from the client stories in her volume.  I see the problems as traceable primarily, though not exclusively, to the practices of psychoanalysis, whereas Bates considers psychotherapy in general to be potentially dangerous – to such a degree that she has suspended her work as a client-centred practitioner.  She believes that we do not yet know enough about the process or outcome of therapy for us to proceed safely.  She has drawn up a list of questions (chapter 13) under headings including heightened emotions, dependence, reality distortion, pathologising tendency, therapist’s emotions and informed consent which we need to consider before we proceed.

The journal ipnosis (www.ipnosis.com), edited by Bates, has a “Voices of Clients” section in each issue, and in her book (chapter 16) House calls for therapists everywhere to join the “client-voice movement”.  Scott Miller (Bates 2006: 159) provides compelling evidence that the effectiveness of treatment is greatly improved by active client participation and feedback. Such a movement is to be welcomed, though I was uneasy reading some chapters, where I felt that the client wanted to blame or control the therapist as a substitute for examining their own issues. While I believe that the majority of the clients had valid grievances, it would be unfortunate if the current problem of therapists blaming or controlling clients were to be replaced by clients being encouraged to blame and control therapists, so that the latter are terrorised out of authentic relationship. Some of the recommendations on informed consent (e.g. p. 103) seemed naïve, impractical and, if implemented, would be very destructive of the therapeutic process.

Rigid adherence to theory (particularly the deliberate fostering of infantilisation, dependence and transference) and failure to listen to clients brought about many of the iatrogenic problems that are described in the Bates book. As one of the therapist-commentators, John Freestone (p. 150) says: “one feature that emerges (to me) is an underlying frustration with therapists who trust too confidently their own theories, practice too assertively and fail to listen to their clients enough”.  Arnold Lazarus (p. 157) exhorts clients to “look for a therapist with a pleasant disposition, someone who does not pretend to know things s(he) doesn’t know, who encourages the feeling that you are as just as good as s(he) is, and who respects differences of opinion rather than saying that you are resisting if you disagree with him or her”. Brian Thorne proposes that every therapeutic relationship might have a process monitor (p. 165), with whom clients can periodically review their therapy experience.

However, as Alex Howard (p. 155) says, (over)-dependency on professionals, not just therapists, is a big problem.  The difference in the issues that stand out for Bates, her 18 commentators and indeed for me all point to the subjective and interpretative nature of the relational and therapeutic process.  Life is uncertain, all relationships are risky and we cannot legislate against this, nor should we want to. John Freestone (p. 150) writes: “Our society is obsessed with defining things, generalizing, having answers and making things safe, but our abstraction takes us away from the here-and-now.  It kills creativity.  It blinds us to what is right before our eyes and thus makes things less safe”.  And – a lot less interesting!  It is clear that questions about psychotherapy need to be asked.  The danger is that, as Ernesto Spinelli (p. 164) warns, looking for certainty, for “a clear-cut and unequivocal answer”, will severely debilitate “the very possibility of a worthwhile meeting” between human beings.

Institutional Ways Forward

How can we meet the challenges raised by Bates and her contributors?  First of all, we need to understand a great deal more about therapy; at the same time we must not fall into the trap of then imagining we know more than we do and having a fixed one-size-fits-all body of theory. Our knowledge should be expanded not through empirical ‘objective’ studies, but through a kind of small-group cooperative inquiry (Reason 1999), or a collaborative approach in which it is recognized that knowledge is fluid and created in relationship, that “the knower and knowledge are interdependent” (Anderson 2003: 204). How can therapy as an enterprise move forward from here? Some of my suggestions are as follows: better screening of trainees; more emphasis on personal development and on critical thinking before, during and after training; and a matching of clients with appropriate therapists, a job that might be undertaken by supervisors. We need to move away from instrumentalising and pathologising in general and view client and therapist as equal partners in life’s journey – with which all of us struggle in our own valid and variously creative ways. We must recognize that much of our suffering has a broad societal cause and respond to that appropriately, e.g. by providing more group support and – taking on our power and our responsibility as a body – by speaking out publicly about unjust, alienating and abusive tendencies in society.  We should go against the current trend and become less rule-bound, more flexible and creative in our ways of working: e.g. as Thorne suggests (Bates 2006: 165) by inviting the client’s significant others to attend occasional sessions.  I will expand on some of the issues in this section in a follow-up article on the institutional dimensions of the trouble with therapy. But I would like to end by acknowledging that what we are trying to do is fantastically difficult.  We need to face up to the limits of what we can accomplish without falling into despair, self-blame or the stifling grip of more or tighter regulation – and embrace humility and an open, questioning attitude.  It is when we fail to acknowledge and respect not just our clients’ but our own humanity that therapy goes wrong.

Barbara Dowds BA, Ph.D., MIACP is a psychotherapist and trainer and is on the editorial board of Eisteach.

References

Anderson, H. (2003) ‘A Postmodern Collaborative Approach to Therapy’ in Y. Bates and R. House (eds) Ethically Challenged Professions: enabling innovation and diversity in psychotherapy and counselling.  Ross-on-Wye: PCCS Books.

Bates, Y. (2006) Shouldn’t I be Feeling Better by Now? Client Views of Therapy. Basingstoke: Palgrave MacMillan.

Berman, M. (1984) The Reenchantment of the World. Toronto: Bantam Books.

Dinnage, R. (1989) One to One Experiences of Psychotherapy. London: Penguin.

House, R. (2003) Therapy Beyond Modernity: Deconstructing and Transcending Profession-Centred Therapy. London: Karnac.

McLeod, J. (2003) Doing Counselling Research (2^nd edition). London: Sage.

Mearns, D. and Thorne, B. (2007) Person-Centred Counselling in Action (3^rd edition). London: Sage.

Reason, P. (1999) Integrating Action and Reflection through Cooperative Inquiry.  Management Learning 30 (2): 207-226.

Rothschild, B. (2000) The Body Remembers: The Psychophysiology of Trauma and Trauma Treatment. New York: W.W. Norton & Company.

Rowan, J. (2005) The Future of Training in Psychotherapy and Counselling. London: Routledge.

Seligman, M.E.P. (1995) The effectiveness of psychotherapy: the Consumer Reports Study.  American Psychologist 50 (12): 965-974.