Eight Reasons Why Therapy Doesn't Work
What are the most common reasons why therapy fails? originally appeared on Quora: the place to gain and share knowledge, empowering people to learn from others and better understand the world.
When I was younger, everyone in my family took golf lessons. My father would obsess over which golf professional he should study with, trying to decide if he was making progress fast enough with one of them, or if he would be better off starting over with a new pro. It seemed that he was on an endless quest to improve his overall score (like many serious golfers). One day he said to me, “you know, I may prefer one pro over another one, but I realized that if I am determined, I can probably study with almost any golf teacher, and learn something from them to improve my score.”
Similarly, someone who is determined to improve their life in the areas that they are struggling with is likely to be able to make progress in therapy many different types of therapists. A person might make faster progress with one therapist over another, or might eventually outgrow their therapist, and be ready for a new kind of therapy to work on a different or more in depth set of goals after completing some earlier work. Except for the most extreme situations, most clients will find that they are likely to learn something and make improvements with a variety of therapists.
Why would therapy fail?
The therapist lacks the specific therapeutic training in the area of need. Some therapists are more skilled than others in diagnosis and treatment. Most graduate schools offer little to no training in personality disorders, yet many clients come to therapy struggling with PD, personality disorder traits, coping with a loved one who has a personality disorder, etc. It can be unhelpful to a client if a therapist is not adjusting their therapeutic approach based on the person’s individual presenting problem and underlying emotional issues. For example: helping someone with schizoid defences develop the ability to connect to their stronger emotions without disassociating or ghosting from the relationship could be extremely beneficial (if this is one of their goals). However, someone who has borderline personality disorder or narcissistic personality disorder does not usually need any help connecting to their “strong feelings”, they are much more likely to need help managing their strong feelings, self-regulating, and improving their ability to maintain a positive emotional tie to someone even when they are VERY angry or hurt.
The client only wants to complain. Many people mistakenly believe that therapy is simply a place to vent about one’s problems. While discussing problems is certainly a large part of therapy, the goal of therapy is actually to work on change. Many people do not actually want to do the work to change what they are struggling with, but merely want to go to therapy to vent every week, without wanting to develop more self-awareness and/or apply this to their life. Therapists are not magicians, and therefore cannot help a person change anyone else besides the client.
The client drops out of treatment. Real change and psychotherapy can be hard, emotional, long, and sometimes expensive. Many people drop out when it becomes harder to stick with it and/or start missing sessions which would not lead to successful therapy. Many clients expect that therapy means going to someone who agree with everything you say, validate and support every feeling and decision, be available whenever needed or otherwise meet some hypothetical fantasy of what that person imagined therapy would be like.
The client is not honest or realistic about their issues. Many people have shame and anxiety about discussing their most problematic behaviours or thoughts and only share part of the story with their therapist. For example, a woman is complaining that all of their boyfriends leave her and she wants to work on recognizing healthy dating behaviours. However, if she doesn’t mention that she is secretly drinking daily, abusing prescribed painkillers and secretly flirting with men on the internet any night she is away from a boyfriend, she is unlikely to succeed at her initially stated goal.
The therapist and client are not a good fit. While most people can make progress with a number of different therapists, there are absolutely times when the client and therapist are not a good interpersonal fit. For example, a client with anxiety about people pleasing, criticism, and shame is unlikely to have successful therapy with a therapist who is constantly confronting them with negative feedback, who often appears obviously frustrated with the client, and comes across as devaluing or otherwise narcissistic.
Success and failure are often subjective. Many people have a subjective idea of what it would mean to have “successful therapy” or “failed therapy”. For example, if a client outlined a specific list of goals to accomplish and they did not accomplish all of them in therapy. Does this mean the therapy failed, or that there is more work to be done? One might look at this same situation and realize that this person may have reduced their overall anxiety, learned some new coping strategies and greatly improved in many areas, even if they have not “completely fixed” everything that bothers them. Most therapists tend to avoid concrete thinking when it applies to more subjective ideas, such as the therapy process. That being said, here are some common reasons why therapy might “fail”:
Client needs a higher level of treatment. Some clients need a higher level of care than that therapist can provide, and this may not have been initially been clear to their therapist. For example: if a client has major depression that is not responding to once per week outpatient psychotherapy, they might need more intensive care, including psychiatric medication, more frequent visits or inpatient care with a therapist who has greater training in treating major depression, and/or a therapist who specializes in treating severe depression and working as part of a treatment team.
Transference/counter-transference issues. Transference and counter-transference are common occurrences in psychotherapy and often it is useful to discuss the client’s transference (if and when it’s appropriate to that person and the type of psychotherapeutic modality). However, there are times when these feelings can create issues that are counter-productive to the treatment, and some therapists will try to offer the client a referral to another therapist who they believe would be better suited to help the client. For example, if a client reveals that he molested a child, and the therapist has a strong negative counter-transference towards the client based on the therapist’s own life traumas, this might make them feel unable to offer the unbiased and supportive environment that this client needs in order to make progress towards developing healthier behaviours. Alternatively, if the client develops a love transference towards the therapist, and despite the transference towards the therapist, and despite the therapist’s clearly stated boundaries, acts out their feelings by continued attempts to touch their therapist, suggesting inappropriate romantic activities, and/or any other boundary violations towards their therapist, this would be unlikely to lead to successful therapy.
The point is…
There are many reasons why clients make progress in therapy, or why they may not. However, despite all of these reasons, the majority of clients who I see who are willing to do the hard work, have realistic goals and expectations, stick with the therapy, discuss any therapeutic issues that come up during treatment and continue even when they don’t feel like it, usually make important, positive progress towards their goals.
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