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.  People often have an initial resistance in going to therapy because they feel that they can or should solve their problems on their own.  It may take a crisis or many years of building up stressors to finally get a person to make that initial call.  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 all can be factors that people use to determine who to see.  These restrictive criteria can severely limit the prospective client’s chances of even starting therapy.

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 the client knows.  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 sibling, due to how I look.

The insurer has substantial paperwork that creeps into the sessions.

The therapist has policies that the client disagrees with, such as about cancellations or the length of treatment.

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.

The insurer does not cover couple therapy, personality disorder treatment, or a whole host of other diagnoses.

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.  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.  Her husband came back to complete our work by doing a follow-up session to process what happened.  I learned that she feared he would use what I said against her.  To progress, it was necessary that I tell her about her own delusions as interfering.  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 given after the assessment but do not try out the suggestions and decide that returning to see me would be a waste of time without following through.  Underlying this is typically 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 the client is not yet comfortable answering, but the client hides this discomfort and makes 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 are dressed 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).

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, or time slots.  When a person is truly ready to deal with their problems, most of these factors become unimportant.

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.

Do not externalize to your therapist, blaming them for your leaving.  Though there are exceptions, such as with malpractice, time slots that are during your normal sleep cycle, etc., quitting so quickly generally is about your own level of comfort with dealing with your issues.

Note that if you become offended by something the therapist does, this may be related to your own issues at home (e.g., the therapist charges you for a late cancellation, and yet you often argue with your spouse about finances).  And so, if you can discuss this offense with your therapist and try doing things differently, this can indirectly or directly help you with your own issues that you came in for help with.  Who better than with your therapist can you work through those topics that push your buttons?  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 07/06 publication, feel free to call him at 860-447-2047 or email him.