I have enjoyed celebrating successful completion of treatment with several clients who had been in therapy previously but who had not found success in that therapy. In this post, I’m going to describe what I do differently when a client comes to me for treatment after prior therapy has not been successful. I’m dividing this post into two types of therapy a client might have experienced before coming to me; Cognitive Behavioral Therapy (CBT) or Psychodynamic Psychotherapy. I will also discuss what I do what both CBT and Psychodynamic Psychotherapy have failed.
When CBT Failed. . .
Cognitive Behavioral Therapy (CBT) is the treatment of preference for many psychological disorders. One reason for this is that the research evidence for the efficacy of CBT is very strong. The process of CBT includes gathering data about symptoms and triggers, trying to make changes in thoughts and behaviors to make a difference in the symptoms, and through a scientific process trying to systematically overcome the symptoms with an individually developed set of thought and behavioral responses. Because CBT can be easily manualized for treating different disorders, it lends itself easily to scientific study.
Given that CBT is the treatment of choice for many disorders, I need to find out why the CBT failed. Based on my experience there are 3 common reasons that CBT treatment may have failed, (1) because the client didn’t do the homework, (2) lack of follow through on homework by the prior therapist, and (3) poor fit between CBT treatment methods and the client’s treatment need.
. . . because the client didn’t do the homework.
If the prior treatment failed because the client didn’t do the homework, I need to find out why the client didn’t do the homework. Sometimes the client lacked confidence that the treatment would be effective. In those cases I may need to help the client gain confidence in the efficacy of the treatment and to identify the specific fears about what it would mean if CBT didn’t work. For example, I might reassure the client that while CBT is the preferred treatment for many disorders, and while I often use it as the first treatment because it is also effective in a short period of time, that if it fails, we have other options for treatment. Sometimes the client was discouraged when the homework wasn’t 100% effective right from the beginning. In those cases, I need to reassure the client that failures at the beginning and setbacks during the process are a normal part of CBT treatment. I may also identify that when a CBT tools fails, that the information about how it fails can help us understand which other tool(s) may be more appropriate. Sometimes there are more personal reasons that the client didn’t do the homework. For example, the client might not do the homework to eliminate anxiety if that anxiety has helped the client to be very successful at work. In those cases, I need to find out how the treatment can preserve the value the client experiences from the symptoms while also helping the client eliminate the unwanted manifestation of the symptom.
. . . because the therapist didn’t follow-through.
If prior treatment failed because the prior therapist didn’t follow-through on the homework, then I need to describe to the client that the problem isn’t with CBT, but that CBT requires a constant attention to data and homework and that without that, it is not likely to be as effective. I will need to help the client gain confidence in my ability to follow that protocol and to make sure that the client is acclimated to the change in my expectations about the client’s completion of the homework.
. . . because CBT wasn’t the right treatment.
If the prior therapy failed because of a mismatch between CBT and the client, I need to figure out exactly what the mismatch is and how to correct that in the therapy with me. The three most common mismatches that I see between CBT and clients include (1) the client has a clinical inability to follow-through on homework assignments (e.g., a client with ADHD), (2) the presenting issue is not a problem but a development process (e.g., a midlife crisis), or (3) the presenting issue is not a problem but a meaning making challenge (e.g., a client grieving a death). If a client has an inability to follow through on homework assignments, we will need to figure out how to overcome that challenge before trying CBT again. If the client is in a developmental process, we will need to engage a more psychodynamic process to help the client synthesize their history and develop their identity. If the client is engaged in a meaning making process, we may need to explore the client’s past values and life meanings, identify how the current stressor is challenging those values and meanings, and encourage the client to develop a new set of values and meanings.
When Psychodynamic Psychotherapy Failed. . .
Psychodynamic Psychotherapy is a slow process of paying attention to the present life of the client, the relationship with the therapist in the present, and biographical details of the client to understand how the client’s past is creating the present through the client’s behavior. These insights are then used to help the client create a new experience of themselves and their life. The research evidence of the efficacy of psychodynamic treatments is not as abundant as the evidence for CBT, but metanalytic reviews continue to confirm that it is an effective form of treatment. One of the reasons that it is not studied as often as CBT is that it cannot be as easily manualized. That is, there are too many confounding variables to study it well as a treatment for a specific disorder. Yet, psychodynamic psychotherapy has been found to be effective and the most promising data suggests that the results are long-lasting.
Based on my experience with clients, if they report that prior psychodynamic therapy failed, the most common reasons they give are (1) poor fit with therapist, (2) too little attention to outcomes during the treatment, or (3) there was a poor fit between the presenting issue and a psychodynamic approach.
. . . because the the therapist wasn’t a good fit.
Because psychodynamic therapy requires such a strong bond between the therapist and the client, it is imperative in psychodynamic therapy that the client is able to feel comfortable and connected to the therapist. So, if a client reports that they didn’t feel connected with their prior psychodynamic therapist, I will inquire about what the therapist did or what happened in the relationship with the prior therapist. This allows me to try to adapt to the client’s needs in advance, or to prepare well for the same challenge to arise in our therapy. Let me explain that last point. Sometimes, psychodynamic therapy comes to a challenging point for a reason. For example, the therapist might challenge the client to notice that despite the client’s fears, the therapist actually cares. In some circumstances, a challenging moment like this (though the therapist is doing it intentionally and consciously for the client’s benefit) can cause a strain in therapy that will bring the client to leave treatment. When I suspect such a moment may have occurred in a prior episode of psychodynamic psychotherapy, I will attempt to talk with the client about what we would do if a similar moment arose between us in the therapy and how we would handle it without it causing the same rupture in the therapeutic relationship. I would also request to talk with the prior therapist. This advanced preparation may help me navigate through a challenging moment that the client went through unsuccessfully in the prior treatment.
. . . because there was too little attention to outcomes.
Because psychodynamic psychotherapy is a slow process, it can sometimes be challenging as the therapist to retain attention on the broad arc of the therapy and to make sure that the client is experiencing changes. For example, the client may have come in with the relationship pattern that is related to their childhood experiences. The therapeutic process of making the conscious connections between those past experiences and the client’s current behavioral and emotional pattern may be the topic of many sessions. If the therapist doesn’t attend to what the client is doing with those insights after the session, the client may get frustrated with a lack of progress. To remedy this situation, I find that my collaborative treatment planning process and regular check-ins with the client about their satisfaction in the treatment can help me to prevent this from happening again.
. . . because psychodynamic psychotherapy wasn’t the right treatment.
Finally, psychodynamic psychotherapy may fail due to a poor match between the therapy and the presenting needs. The two most common examples of this are (1) the client is experiencing an acute condition like panic attacks or PTSD, and (2) the client doesn’t need to understand why but needs answers a whether question. In the first case, I find that CBT methods are best for more acute conditions, because they focus on helping the client to develop skills and tools to reduce the immediate suffering. After that suffering has been relieved, it can be beneficial to attend to insight oriented questions like, how the client’s past might have led them to experiencing the acute condition in the first place. If the client needs to answer a whether question like, “Whether or not I want to leave my spouse?” or “Whether I will change career paths” these questions require sense of the present more than a sense of the past. They also require attention to the client’s values, the meaning they find in different experiences of life, and what kinds of relationships they find fulfilling or don’t. While a psychodynamic lens may be helpful in understanding the origins of the present moment, it does not attend as immediately to the personal agency that the client has, regardless of their history, to build a life now of their own choosing. Our individual agency to affect our future is not limitless, but it is an awesome power nevertheless. Forks in the road in our lives can paralyze us for that reason; not because we are anxious, but because we are stunned with the enormity of our own power to change the future.
When Both CBT and Psychodynamic Psychotherapy Failed
I have been alluding to Existential-Humanistic Psychotherapy throughout this entry without naming it. While CBT and Psychodynamic Psychotherapy complement each other well, sometimes the right next choice is “Neither”. When a client has had unsuccessful therapy in CBT and psychodynamic therapy, I am most inclined to try an Existential-Humanistic approach. Existential-Humanistic psychotherapy emphasizes humanistic responses to the four existential truths of our mortality, our aloneness, our terrifying freedom, and the apparent meaninglessness of life (i.e., the definitive answers are not written down somewhere in an irrefutable way). Those responses are more like questions or invitations than answers. When clients are grieving, existentially disoriented, or uncertain about their place in life, sometimes they need to attend to those big questions. Many people need to face the enormity of life and death, of suffering and evil, and only then do they find that they can rest peacefully in our present moment.
I do not always get the opportunity to utilize Existential-Humanistic methods yet I find that work very satisfying. I also find that because of my exposure to Existential-Humanistic methods, I apply both CBT and psychodynamic psychotherapy with a different tone than many other therapists. Psychodynamic training often leads to the assumption in the therapist that the therapist knows best. CBT training leads to assumptions that the methods and techniques are paramount and if the client will just learn and apply the skills they will get better. Based on my Existential-Humanistic background I bring a degree of humility to these methods. I may have ideas about the psychodynamic cause of the client’s relationship pattern but it is the client’s choice about whether or not that insight resonates that determines its value. I may have tools to help client overcome anxiety but it is the client’s decision whether or not to use those tools. This tends to make me less reactive to moments when my clients resist my efforts to help them. I am inclined in those moments of resistance to pause and consider my own values and the meaning I am giving to the interaction, rather than blame the client for what is happening.
In subsequent posts I will identify what I do differently when prior couples therapy has failed.