4 ways therapy can do harm and why that is good news.

My former supervisor and teacher, Sylvia, used to tell me, "If you are stuck with a client, you need to put that on the table.  If you and the client can't get unstuck, stop the therapy."  I have been thinking about what great advice that is and how hard it can be to follow.  Clients will often say to me, "More therapy can't hurt, right?"  I even hear that from medical professionals and sometimes mental health professionals.  Generally, people know that insulin can hurt, and they don't take it just 'cause.  People don't undertake minor surgery for no reason.  Aspirin if taken improperly can put a person in grave danger.  If a therapy is capable of affecting someone's well-being for good, then it can also do harm if administered when it isn't indicated or in ways that aren't indicated.  Stated another way; If it can't do any harm then it is not worth doing.  I am not talking about an abusive or incompetent therapist or an unproven therapy.  I am talking about how psychotherapy can hurt when administered properly for the wrong situation or in the wrong dosage.

1. Psychotherapy directed towards a fundamentally well person in a bad situation can make the person feel responsible for his or her situation and aggravate worry.

This one happens with kids a lot.  The parents come into a therapist's office and say, "My kid is anxious/sad/angry all the time.  We don't want to discuss our fighting/grief/parenting.  Work with the kid."  The therapist can treat the kid using behavioral techniques for tackling whatever his/her symptoms might be.  I have heard therapists say, "At least I can offer the kid tools for dealing with X that may alleviate one difficulty in a difficult life."  I don't agree with this.  I think treating that kid in isolation gives the parents license to continue their behaviour and can put the spotlight on the child whose symptom is really the family's.  This may exacerbate feelings of responsibility for the family's difficulties.

2. Therapy that doesn't change the music.

This one happens with couples often.  Couples will come into therapy and insist on having the same arguments that they have at home.  I often say to them, "It's okay to fight in therapy, but I want you to at least have a different fight than you have at home."  Therapy is about making change in patterns and if you are doing the same thing in therapy that you are doing at home, you aren't changing a pattern, you are rehearsing it and you may be reinforcing it.   Some couples can't stop this, which is painful for therapists and the clients, but rather than have a bad experience of therapy and a lot of extra practice doing what hurts, it is better to stop therapy.  The couple may be able to come back when they are in a different place or work with a different therapist who can get them pointed in a different direction. 

3. Psychotherapy in place of something else that would give more well-being.

People are busy.  Therapies can be expensive.  People may prioritize psychotherapy over other things, either other therapies or other activities that could improve their well-being.  People are often choosing between therapy and a gym membership or a babysitter or a speech therapist or a soccer practice.  Those can sometimes be false choices but I actually think that more often than not, they are real.  I am all in favour of people prioritizing their mental health and their close relationships but the best expression of wellness is living a full life, not being in therapy.  Sometimes people believe, mistakenly, that because they are in therapy, they are taking care of their well-being when, in fact, they are using therapy as a smoke screen.  A good question for clients and therapists is "If the client wasn't here, where would s/he/they be?  What does missing X mean?"

4. Ending too early.

The pioneer of systemic, family therapy, Salvador Minuchin pointed out that sometimes people try something new to make a change but stop early when they see no benefit.  Some changes yield benefit in a one-to-one ratio -- a straight ascending line -- but sometimes change comes more as an exponential curve or even a "hockey stick" curve in which a person sees little benefit at first but experiences big pay-offs when s/he persists.  The down-side of ending early is that it can feel disheartening to work at something and see no result.  Depressed people often cognitively distort failures so that is all they see and they see those failures magnified.  If a depressed person tries cognitive behavioural techniques in therapy, for example, and doesn't experience change fast enough s/he can view it as yet another failure and feel worse.  Going back to the surgery analogy, if we abandon surgery in the middle the results will be not only a return to pre-surgery function but worse functioning. 

Avoiding these pitfalls is part of providing good therapy just as providing good medical care involves more than just prescribing medication, but knowing when and where to prescribe and when not to.  All this isn't meant to scare people off therapy, but rather to point out that therapy has real effects.  If a therapy isn't working, feels like it is hurting more than it is helping or feels stuck, take the time to look at that, client and therapist together. 


Important Parenting advice! Ignore Parenting advice!

When did "parenting" become a word?  When a publisher realized that there were millions to be made from telling anxious, well-off parentingers about all the things that can go wrong with kids.  (And a guy named Stan, in marketing, suggested they move away from the term "child rearing").  Nobody ever sold a book called "If You Can Afford the 30$ to Buy This Book Then Your Kid Is Doing Better Than 99% of the Humans Who Ever Lived."  21st century Canadians live in an age and place where most of us can provide our children with nutritious food, shelter, education, clothing and medical care that most of our ancestors (and many people around the world today) would have been delighted to be able to give to their kids.  That and love will go a long way.  We live in an age and circumstance of tremendous blessing.  So why do we consume parenting advice books and lectures by the SUV-load?

I work with a lot of families in difficult situations and I have seen some pretty bad parenting (by today's standards).  I can tell you that very little of what I have seen happens because people didn't read a book on parenting.  Occasionally, I will meet parents who honestly did not know better.  I tell them to stop and, usually, they do.  Twice in my career I have told parents not to threaten to hit their kids with a belt.  These parents felt overwhelmed by out-of-control kids and thought that threatening such a beating was better than actually following through.  I told them that, for a kid, the fear of such a beating can be almost as devastating as the beating itself.  They thought about it and saw that what I was telling them was probably true.  We brainstormed some better ways to deal with their kid's behaviours and they never resorted to that kind of threat again.   

I see parents who want to stop doing things they know or suspect are bad for their kids but they can't because they have mental health issues or are struggling with the ghosts of their own past or trouble in their present.  Just about everybody knows that parents should keep their marital acrimony away from their kids.  There are dozens of books that will tell you that.  But I have seen a lot of parents who tell me that in their particular circumstance, because their soon-to-be-ex wife/husband is such a poisonous viper, it is absolutely critical for the kids to know everything.  Or they make every effort to hold back only to find themselves pouring out all their hatred to a kid who is caught in the middle.  A book may help re-inforce a message in such a circumstance but I think that person needs supportive friends, a caring community and probably counselling.  

The people who buy books on parenting are often the worried well; parents who lack confidence in their own ability to parent.  That is where I have the biggest issue with the parent-advice-industrial complex.  By turning something that humans have done pretty successfully for our whole history into a gerundified 'parenting' with classes and manuals and DVDs, it makes parents feel less confident in their own judgement rather than more confident.  Ron Taffel wrote a wonderful piece in Psychotherapy Networker a few years back called "The Decline and Fall of Parental Authority... and what therapists can do about it."  He wrote about some of the forces undermining parental confidence and what that does to people's lives.

[A] chronic sense of being held hostage by kids and the culture at large helps explain why parents so often show up in our offices looking and sounding like spineless wimps. With so little time to bond with their children, parents are afraid to take even one step that could drive them farther away, undermine their already shaky school performance, and ruin their chances for social success when little else seems to matter. Not surprisingly, a multibillion-dollar public and private enterprise monetizes these insecurities by selling a raft of social modules and remediation services—including tutors and homework helpers for the well-heeled and supplemental educational materials designed to jack up reading and math scores. The issue isn’t just parental abdication, but what I call the “merchandising of childhood,” based on a deep-rooted fear of failure.
— http://www.psychotherapynetworker.org/magazine/currentissue/item/1645-the-decline-and-fall-of-parental-authority/1645-the-decline-and-fall-of-parental-authority

Taffel sees economic difficulties as the driving factor in parental lack of confidence.  I would go one step further;  I think we live in a fear culture.  We are encouraged to be fearful rather than generous and open towards people and the world around us and we are especially encouraged to transmit those signals to kids.  Engagement in community organizations has plummeted in North America over the last 50 years.  People don't join clubs, religious institutions civic organizations.  In Robert Putnam's famous phrase, today people are "Bowling Alone."  And people are 'parenting' alone as well.  Living in a more mobile, deracinated society that is fearful and highly individualistic means people don't have great social networks for parenting.  There are fewer norms for parenting and the norms that exist are harder to learn than they once were.

That makes for a lack of what social scientists call self-efficacy among parents; basically the feeling that you know what to do and are able to do it.  That is a problem because self-efficacy in parents correlates highly with good outcomes for kids.  (Obviously, if you are convinced that the way to deal with a kid is by threatening to hit him/her with a belt or to dis your ex to the kids, that's not good.  But it is better to parent with confidence than to parent without confidence, even poorly, and parents who feel confident in their parenting are less likely to parent badly.)  Researchers don't know exactly why that is the case, whether confidence comes from success, or if it comes from shared norms and those things generate success in parenting or maybe that kids perceive confidence in their parents and feel a sense of safety because of that.  Or a combination of those things.  But it is clear that feeling that you can manage being a parent without getting post-doctoral training in child development and arts and crafts is good for families.  

This doesn't mean that parenting books can't be helpful for everyday kinds of problems with kids.  I have mentioned "How to Talk so Kids will Listen, How to Listen so Kids Will Talk" before which I think is great.  But I actively discourage parents from trying to anticipate and preparing a fully developed response to every potential disaster of childhood and adolescence.  Now if you'll excuse me I have to go work on the next chapter of my parenting book.  The working title is "1001 Things That Will Definitely Go Wrong With Your Kid That Only This Book Can Fix."        

Your therapist, Ron Swanson?

Men often fear that therapy is stacked against them.  Whether it is couple, family or individual therapy, they think that they are entering a domain where their skills and strengths will be counted as liabilities and they will be asked to do things that aren't just difficult or scary but unbecoming.  That isn't a man problem.  That's a therapy problem.  I was talking recently with another male therapist, Dr. Darrell Johnson, a friend and mentor.  I mentioned this campaign to him... (Okay, it isn't Ron Swanson but a Ron Swanson knock-off.)

It is from the Office of Suicide Prevention of the Colorado Department of Public Health and Environment.  It's geared at connecting with men, particularly working-age 25-54 men who are twice as likely to commit suicide as any other age group according to the white paper that was used to develop the Mantherapy campaign (US stats).  Darrell and I talked about the idea that men are typically more resistant to therapy (part of what accounts for their higher suicide rates than women).  I joked that soon it would be possible for therapists to use cookies to give different design templates to their websites so that women and men would be presented with different web sites that are gender specific since too much "feelings" language might be off-putting for men, essentially presenting themselves as Rick Mahogany when men click through.  But the Colorado campaign doesn't seem to have been a raging success despite the high production values.  The Richard Mahogany video that has the most views on YouTube is at around 8,000.  Maybe those are 8,000 saved lives and if so, great, but I don't imagine that therapy's problem with men has been touched much.  I think the character seems inauthentic, not just playfully unreal, and for men or women authenticity in therapy is important. 

There were a few things in the white paper that I thought were really interesting for therapists to consider about working with men, things that hadn't occurred to me despite having worked with boys and men a lot.  One is the value men often place on fixing something themselves and how to make therapy an exercise in 'solving it myself (or ourselves) with help'.  One man said to the researchers of the white paper, "Show me how to stitch up my own wound like Rambo."  Okay, that's some pretty serious hyper-masculinity but the point is that therapy can benefit from emphasizing the client's efficacy in problem-solving with the therapist as trusted assistant. 

The other thing that I thought was really wonderful was the importance some men place on giving back.  I was in Hawaii last year.  A companion and I went kayaking.  We visited a small island and had a great time but when we went to get back in our kayak, we got hit by several waves in succession and my companion got knocked over in the surf and couldn't get up.  I watched, barely able to keep myself afloat trapped on the other side of the kayak thinking I might very well see this strong, capable person drown before my eyes in three and half feet of water.  But before that could happen two kayakers (much more capable than us) grabbed our kayak and my companion, hoisting him out of the water.  I thanked them.  They said, "That's what we do."  They viewed helping as part and parcel of who they were.  I, on the other hand, felt grateful but unsatisfied as they paddled away.  I couldn't pay back the debt I owed them.  Therapy is a uni-directional process as far as help goes; codes of ethics forbid outside relationships so it is very hard for a client to pay his debt with his skills through labour exchange or barter.  I never thought about how important it can be for some clients to be able to show their competency and mastery to a therapist by doing meaningful work or sharing their own products, to give help for help received, and that men might feel that more acutely.  The report points out how central the idea of repaying a debt is to AA, for instance.  Now I am considering requiring clients in some circumstances to agree to pay part of the cost of therapy by "paying forward" to others using their own strengths and capabilities (see the Milwaukee African Violet Queen).  Ron, would like the idea of paying off your therapy by carving duck decoys with kids in an after-school program? 

"I'm a a bit fearful that we are verging on what I call 'feelings territory.'"

Therapy, including family therapy, is helpful and important even in the age of SSRIs

From the New York Times.  Despite the dire title, I find this article hopeful. 

...for patients with the most common conditions, like depression and anxiety, empirically supported psychotherapies — that is, those shown to be safe and effective in randomized controlled trials — are indeed the best treatments of first choice. Medications, because of their potential side effects, should in most cases be considered only if therapy either doesn’t work well or if the patient isn’t willing to try counseling.