Bad Therapy

In the book “Bad Therapy: Master Therapists Share Their Worst Failures” by Jeffrey A Kottler it shows how other therapists use psychotherapy and how the therapists deem certain sessions as bad therapy. When the authors began this work their aim was to create an opportunity by which some of the most prominent therapists in the field could talk about what they considered to be their worst work in order to encourage other practitioners to be more open to admitting their mistakes. The authors are among the 22 therapists who agreed to participate in the project.

The result of the interviews, all conducted over the telephone is this collection of short and very readable accounts. The credentials of the list of contributors to the book are impressive. In the preface the authors explained that they selected the participants because all were prominent and influential, had a body of published work and years of clinical experience. Arnold A. Lazarus, a pioneer of Behavior Therapy is among the writers. Between them, the authors alone have written over 70 books on counseling and psychotherapy. The majority of these therapists are working in a public professional life.

They write books, run training courses, lecture and demonstrate their techniques to large professional audiences. They produce tapes and videos of their work. Throughout the text there are many references to the anxiety stirred by the nature of the subject on which these therapists were asked to reflect this because of the possibility of a lawsuit and laws. Each chapter is a narrative account of the conversation the authors had with the therapist who was asked to talk about incidences in his or her clinical practice which evoked uncomfortable memories, feelings of regret or guilt, or a sense of failure.
Strong emphasis is laid upon what can be learned from the mistakes. I found this and the more general reflections on the theme of what makes therapy bad helpful to me considering a career in the clinical practice. The refreshing honesty of the therapist’s accounts that gave me a sense of the tensions that arise during these sessions, “projecting an image of perfection”, and “stories of miraculous successes” (p. 189) or the “stunning failures” (p. ix). These words made me reflect on the nature of idealization and its opposite, devaluation on what success and failure means in therapy.
It also helped me to reflect on the high expectations we put on ourselves as therapist to train well and to be viewed as doing a good job in the eyes of our clients, peers, trainers and supervisors. There is an uncertainty to what we view as good and what is bad in therapy. Good and bad can become intertwined with emotionally charged meaning along the success-failure road and their use is dependent upon expectations of good techniques or good interpretations. The value of the ordinary human contact with the client can get caught up in an anxiety ridden preoccupation with the right way of doing things.
At the beginning of the book, the authors state that they “tried for a cross section of representative styles and theoretical orientations” (p. x). But none of the 22 contributing therapist practices in the psychodynamic tradition. The therapeutic relationship is known as being important and the interaction between therapist and client is very much the basis of what happens in these accounts but the term “transference” is used only once or twice and not explained.
The term “countertransference” is used in several places and in the context of some exploration of interpersonal dynamics but this is not explained either as a concept or as a useful frame within which to understand what happens in the emotional field between therapist and client. One of the few exceptions occurs in the discussion between the authors and Richard Schwartz (p. 51-52) in which the therapist talks about the importance of noting countertransference thoughts or behaviors, commenting that many therapists do not think about their own emotional responses to their clients.
In several accounts, the therapist was left with a hangover of guilt or regret as a result of the bad therapy practiced. If a detailed exploration of the transference and countertransference dynamics had been possible then I suspect the focus of what was bad might have been shifted from it being a bad technique or an unfortunate intervention or maybe strategy to the kind of understanding that psychoanalytic psychotherapists are more familiar with.
Also the impact of unconscious projection and introjections upon ourselves and our client’s behavior or emotional response, an example was given of this occurrence in the first chapter when the therapist, Kottler, briefly describes how he got mad at a client who would not dump her abusive boyfriend, and told her not to come back because he could not help her and then hoped she received better care elsewhere from another therapist.
If a way of attempting to unravel what happened in this session were to think about the repetitive actions of an explosive situation in the client’s life during the session, the conclusion that this was bad therapy would be different. The kind of understanding that a psychodynamically trained therapist or counselor brings on some of these accounts made gave me a sense of what could happen during a session, such as Jeffrey Kottlers confession to sometimes feeling invisible and irrelevant as part of the personal process he encountered in interviewing the contributors (p.
195). Both authors remarked that the contributors did not “go deeper” (pgs. 195, 197). Neither really explains what they meant by this and I suspect a similar sentiment is felt by many therapists. I felt there was a certain lack of depth and substance to the book because of the absence of consideration of the workings of the unconscious mind. The meaning of “bad therapy” must be deemed by individuals reading the book.
But in the book bad therapy means “In summary, bad therapy occurs when either the client or the therapist is not satisfied with the result and when that outcome can be traced to the therapist’s repeated miscalculations, misjudgments, or mistakes” (p. 198). It would be very interesting to extend this question of what makes for bad therapy by opening a clinically orientated debate among psychodynamic counselors and psychotherapists. What is the difference between bad practice and bad experience in psychotherapy and counseling would be a good question to pose.
Both the therapists and clients may from time to time have a bad experience of each other or of the effects of our words or of feelings which cannot be thought about or adequately contained in a single moment. If we are open enough to be available to receive our client’s projections and be affected by emotions unconsciously intended to be a communication, we will no doubt feel the bad emotions or the mental state being projected. It will be enough to call this countertransference.
If a bad experience is not able to be recognized then transforming the experience into something understandable in terms of the need of the client or even the mental state of the therapist it could become an example of bad therapy. What makes for bad therapy cannot be limited to doubtful strategies or mistimed interpretations or the wrong techniques. We are human in relationship to another and constantly affected by the emotional impact the other has on us if we are not really emotionally present to the client for some reason or if the client is using the therapist to communicate his or her experience of not being responded to emotionally.
The point is that therapists need to find ways of transcending the experience so that it can be understood or changed by being given the benefit of thoughtful reflection. This may be a result of consulting our internal supervisor or of talking with a trusted peer group or external supervisor or consultant. Another related question has to do with the responsibility we take upon ourselves for monitoring and understanding what we call countertransference. In the book the point is made, several times, which we can all too easily label or blame our clients for their bad behavior or resistance or ability to make us feel tired, angry or irritable.
Are we so focused on what the client does to us and on using this as a helpful therapeutic tool that the therapist will lose sight of their own state of mind or emotion which Freud cautions in relation to countertransference may be interfering with therapist’s ability? We need our peer colleagues and supervisors to help monitor therapists state of mind and reactions to their clients so that the ability to enter into the experience of the encounter with the client does not turn into a case of bad practice due to the absence of reflective thinking or insightful monitoring.
I would recommend “Bad Therapy” to both trainees and the more experienced counselors and psychotherapists for its very thought provoking and interesting content as well as the unusual opportunity to gain insight into the mind and emotions of the practitioner at work. Reference: Kottler, J. A. , & Carlson, J. (2003). Bad therapy: Master therapists share their worst failures. New York: Brunner-Routledge.