Unsuccessful Psychotherapy:  How it Can All Go Wrong Before or During the Initial Sessions

Psychotherapy has some of the highest no-show and cancellation rates in the healthcare industry.  Often times people blame the therapists, but is it possible the clients have a strong hand in whether or not the therapy is successful?  This article seeks to address how a client can take ownership of the outcome.  People often have anxiety going to therapy because they fear being judged, or they feel that they can or should solve their problems on their own.  It may take a major crisis or many years of problems that won’t go away before making that initial call to a therapist.  Many people then will go only if the therapist can accommodate special times, such as only early evenings, and take their insurance, even if it means that the quality of service might be compromised by the insurer’s policies.  Additionally, the therapist’s location, gender, phone friendliness, and age can be factors that people use to determine who to see.  All these criteria can severely limit the prospective client’s chances of even starting therapy, never mind continuing.

Much of the above also applies to people who begin seeing a therapist.  There are additional factors that come into play when starting therapy:  

Sometimes the therapist resembles a person you know.  For instance, I once starting seeing a couple and the husband looked like he was ready to crawl up the walls.  I later found out that the issue was that I reminded him of his brother, due to how I look.

The insurer has substantial paperwork that creeps into the sessions, directly or indirectly.  In most cases, this will lower the quality of treatment.

The therapist may have policies you disagree with, such as about cancellations or length of treatment.  In my own practice, I sometimes get people that want to come in just when they want to come in.  While I’ll ultimately agree to the terms, at least for a time, it is very rare (perhaps 3% of the time) that such clients gain much out of the therapy.

The insurer states that there is a deductible, but the insurer applies only a fraction of the fee paid toward it for therapists who do not have whatever particular license type that the insurer prefers.  And so a deductible that should have been used up in a matter of five sessions ends up taking ten sessions to be used up.  (E.g., the therapist charges $200 per session, but the insurer pays the license your therapist has at the rate of $100 per session).

The insurer does not cover couple therapy, personality disorder treatment, or a whole host of other diagnoses (nowadays most therapists will see the main issue as, for example, a partner relational problem, but will give a mental illness diagnosis to get coverage).

It turns out that the therapist does not specialize in the issues needing treatment.

The therapist offends the client:  I once had a couple, and the wife was experiencing paranoid delusions (believed things that were not true).  I recommended that individual therapy would be needed for her to work on how her beliefs affect her and the marriage, but she became very upset and abruptly walked out, never to return.  She said that her husband was going to use what I said against her.  But, had I told her separately, and she was not willing to disclose what was said in private, he might have walked out for the secretive nature of this one-on-one meeting.

The therapist gives or does not give suggestions: Some people appear to be interested in constructive feedback, but do not try out the suggestions and decide that returning to see me would be a waste of time without utilizing the suggestions.  Underlying this often may be a person who was raised by critical parents, causing them to fear letting their therapist know that they didn’t progress.  In reality, sometimes not doing an assignment is more useful as data to the therapist than doing it.  At other times, therapists see people who do not show any request for direct suggestions, then they stop coming in because they did not get enough direct suggestions, even if the therapist is still assessing and getting to know their new client.

The therapist asks questions that you are not yet comfortable answering, but you hide this discomfort and make a decision then and there to not return.

The therapist is unprofessional or too professional: I know of a therapist that, particularly with teenagers, uses swear words.  I also know that some therapists dress wear a suit and act so professionally that some people are uncomfortable.

The therapist is practicing out of their training, such as one who has no formal training in seeing couples, or does not specialize in it (experience can be informal training, but is not always a substitute).  The article published several years ago stated that the majority of therapists practicing couple therapy have no formal training in it!

With so many factors that can prevent a successful therapeutic relationship from forming, what can you do?

Be picky with a therapist’s experience, education, or skills.  But within reason, try to not be picky about factors such as age, gender, cost, distance, or time slots.  If you hate women, then see a woman while allowing her to be the exception to your hatred.  Who better than a woman than to help you through your misogyny [if you can allow her to be the exception].  If the therapist has no evening slots and is the highest recommended person, find a way to make it in if it is at all possible.  Who better to help you than the top-rated-for-you therapist in the area?  When a person is truly ready to deal with their problems, most of these factors become unimportant.  People who can overcome all obstacles to utilizing the best help typically utilize the treatment vastly more.

BE HONEST!  Do tell your therapist what your needs are, so that you can see if they use a style that works for you.  For instance, I am typically an active therapist who provides much useful feedback, but I also have training and experience at slower paced models.  I do need people to let me know what they need, and if it is within my abilities, I will provide it.  Say when something bothers you and you can work it through with your therapist.  People usually have the same issues with direct communication in their personal lives, so do not give up so easily when you get uncomfortable.

Do not blame your therapist for why you want to quit.  Exceptions include malpractice (i.e., the therapist trying to start a romantic relationship with you, or the therapist has no training in what they are trying to help you with), or they only have 10PM to 2:00 AM time slots available, and your normal sleep pattern would be harmed by attending.

Note that if you become offended by something the therapist does, this may be related to your own issues at home/work/family of origin (e.g., the therapist charges you for a no-show, and you often argue with your spouse about finances, or the therapist talks to you about your being late, when being late is what you often do), and so if you can discuss this offense with your therapist and try doing things differently, this can help you with your own issues that you came in for help with.  Who better with, than your decade-long trained therapist, to work through those topics that push your buttons?

The bottom line is that sometimes finding a therapist with whom you feel most comfortable is not always going to be the most productive for you.  

Samuel Schaperow, M.S., LMFT is a licensed psychotherapist practicing in Waterford, CT at 567 Vauxhall Street Ext.  If you have any questions about this article, feel free to call him at 860-447-2047 or email him