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Gift From Within - Questions & Answers with Frank Ochberg on PTSD
|Recovery: Inadequate Therapy.
Q: Dear Frank:
A colleague wrote about a fairly common situation, dealing with a therapist who just isn't getting the job done... "This man's wife was in therapy for DID. The husband felt that after years with this therapist that his wife was not getting any better. He asked the doc to talk with another trauma specialist. The doc really did not want to do this and said a consult was unnecessary. Long story short...the consultant advised the husband and wife to find a more qualified therapist after speaking with the doctor. He advised her to find someone who knew about EMDR and other therapies for DID and trauma related symptoms. Outcome was excellent. Turned out the wife feels more optimistic about recovery with her new counselor and was appreciative that her husband made this effort.
What do you do when you find yourself with an inadequate therapist?"
A: Dear Joyce:
There are some websites out there that offer very reasonable perspectives. See
http://www.stopbadtherapy.com/test/therapy.shtml and also our pages where GFW support pals talk about finding a good therapist in the first place,
http://www.giftfromwithin.org/html/spfind.html. And here is an article by Sidran on choosing a therapist, http://www.giftfromwithin.org/html/therapy.html
A good therapist has training in techniques for reducing anxiety and overcoming traumatic memories. A good therapist has education in science and the humanities, and should let you know where he or she received that education. A good therapist is ethical. The various codes of ethics for psychologists, social workers, nurses and medical doctors (including psychiatrists) require practicing according to scientific principles, respecting the privacy and confidentiality of clients, and doing no harm. Good therapists may be firm and strict at times, but they need not be unpleasant. Inadequate (rather than unscrupulous) therapists often waste the hour talking about themselves, or allowing meaningless small talk, or being "supportive" but not really tackling obvious issues. They will not go the extra mile. They charge for things that they ought to do free, like sending records and writing reports and talking with colleagues about your case. They do not keep up with advances in the field. And they are not particularly respected by colleagues.
I've supervised a few of these inadequate therapists at various times in a long career. They are not necessarily bad people. But, in my opinion, they are bad therapists and I wouldn't send a client to them. George Carlin once said, "If you ranked all the doctors from best to worst, you could find the worst doctor in the world. And somebody has an appointment with him at 9AM tomorrow morning." So don't you be that doctor's patient!
It isn't easy to leave a therapist. They can act in ways that make you feel responsible for their hurt feelings or they can assert authority and be intimidating. They may write notes in records that suggest that you are a difficult client. They may make it difficult for you to get your own records, short of a lawsuit against them.
(I read my notes to my patients so that they know what is in the record and so that I know if I have made a mistake. But I also want the therapy to be collaborative and I don't want to record something that I wouldn't say out loud to my patient. We are a team, dealing with a common adversary: the lingering impact of trauma and tragedy. And even when my patient has a self-defeating personality disorder, we can be honest and clear about that, figuring out ways to retrain inter-personal habits.)
So let's assume you have decided that your therapist does not meet your needs for progress. You have some hard choices. You could be frank with your therapist. If your therapist takes offense and says anything demeaning, you'd be best off with a polite but firm statement that you are terminating therapy. You have no obligation whatsoever to help a therapist recover from a "divorce." Our professional training prepares us for this and our ethics require us to shoulder the complete responsibility for our own feelings, should this happen.
If your therapist has a mature and enlightened response, she or he will make it easy for you. A therapist could and probably should question whether the issue is related to your own sensitivities and stressors. For example, as you get close to a painful piece of personal history, say a betrayal by a relative you trusted, you may be particularly sensitive to innocuous statements or mannerisms of a therapist who reminds you of an abuser. This is VERY common. And you would be advised to stay with therapy if that is the case. But you can't always tell, and it may be that your decision to change therapists is the right decision. That mature therapist could suggest others, could agree to a "second opinion," could seek consultation for herself, or could simply wish you well and do it in a reassuring way.
Since most of us therapists are somewhere between the extremes of very enlightened and just plain inadequate, we will probably complicate this awkward situation to some degree. And that means you can use support from the outside. In the case that raised this issue, the support came from a terrific spouse. There are supportive GFW correspondents. There are web resources. There are also professionals who will be willing to see you, whether or not they end up as long-term therapists. These may be general physicians, nurses, mental health professionals or others who have "been around the block." Think about the mature, selfless, experienced people that you know. And avoid the sort of friends or relatives who have a knack for making you feel worse about yourself. A supportive person will help you transition from one therapist to another, feeling as good as possible about yourself, considering reasonable options, and avoiding too much stress and loneliness as you take a difficult but necessary step.
What if your therapist is really bad? They might be abusive, sexually inappropriate, or alcoholic. Some become senile. Some use illegal drugs on the job. I had a patient whose previous psychiatrist prescribed tranquilizers and asked the patient to "kick back" a portion of the drugs for the therapist's own use. I asked that patient to help me report the doctor to the licensing bureau, but she really didn't want to do that. State law did not allow me to complain without confirmation from the patient. So I did what my patient preferred since I was a doctor, not a law enforcement officer. (I followed the career of the offending psychiatrist and was relieved to learn of her early retirement). If you have a really bad therapist, your first duty is to yourself. Get away. Get a good therapist. Don't blame yourself. If you have the will and the time and the fortitude to report a bad therapist, there are ways to do it effectively. A trial lawyer can let you know if you have a malpractice or personal injury case. (I've written elsewhere on finding a good lawyer: http://www.giftfromwithin.org/html/findlaw.html This article is addressed to therapists, but it can help you, too.) My state has an Office of Recipient Rights. See: http://www.michigan.gov/mdch/0,1607,7-132-2941_4868_4901---,00.html Your state may have a similar department. They are particularly sensitive and skilled in helping clients of public sector therapists report abusive therapy situations. But if you are seeing someone who has a private practice, this office has no jurisdiction. They will suggest contacting the state licensing authority to discipline a practitioner, or the police to report a crime.
What if your therapist is young, or is still in training? I'd hope that a therapist in her or his twenties, just starting out, would accept advice to call a mentor, to involve a supervisor, and to let you speak with such a person. I've seen this happen, sometimes successfully and sometimes, not successfully. A client of a young therapist became romantically attracted to her therapist. The therapist ended therapy, and placed disparaging notes in the chart. I got involved through a friend of a friend and counseled the therapist to seek consultation for her own "countertransference problems." It worked for a while, but then broke down. I got the Office of Recipient Rights involved, and that resulted in the client getting a senior therapist. Some young therapists have room for growth and need to learn how to deal with clients who present challenges. And let's face it. There aren't enough senior, experienced, wise therapists to go around. So working patiently with a promising young therapist can create, in time, a wonderful older therapist. I've made my share of mistakes, and am thankful for the patients who helped me grow up on the job.
In sum, there are bad therapists. You may have encountered one. If you are being treated by someone who isn't really helping, you have a right to find someone better. You needn't fret too much about the therapist's feelings (although it is perfectly normal and rather nice of you to have caring concerns). Therapists should be trained and equipped to handle their own stress. You may need professional help to deal with the damage done by a really bad therapist. A good lawyer is prepared to offer the ultimate help - a lawsuit to obtain security and justice for you, and to protect future clients from a predator with a license. You deserve support during the transition from one therapist to another. There is no "one size fits all" transitional support. Think carefully about friends, family and web resources that are truly in your corner. We certainly try hard to make GFW one of those resources that you can count on.
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