I've written a series of blogs about what I think are the 10 most common mistakes that we therapists make. Notice that I call them common meaning that we all make them and they are typically not very harmful in and of themselves. I am very familiar with them because I have made them myself, many times. I point them out because I believe that in noticing our mistakes, we are acknowledging that we are human and are still in process just like our clients. I like to poke a little fun at us, which is why I try to use humorous cartoons as well as to acknowledge that I am speaking to myself as much as anyone else. So I am listing the 10 together in one blog with links if you'd like to read the expanded version of each message including case examples.
We therapists want to believe what our client's tell us, however it usually isn't up to us to judge the truth of what we hear and is often not even in our clients' best interest. It is better if therapists try to avoid taking sides and beware of unknowingly validating patients’ distortions or projections because such actions can leave patients stuck in personal narratives or beliefs that may be ruining their lives. Suffice it to say that if our patients’ perspectives were always accurate, they probably wouldn’t need to be in therapy. Valuable therapy time is wasted when we follow a patient down a well-worn path of blaming others rather than empowering the patient to shift his thinking or perspective to be more effective. I often tell my patients that if they want to blame others, they have every right to do so, but I want something even better for them, and that is that they focus on themselves and what they need rather than give that power to anyone else.
One of the most common mistakes therapists make in dealing with ambivalence in psychotherapy is to engage in a power struggle with a patient. Often when a patient is ambivalent, he may voice only one side of his ambivalence at a time. For example, if the patient says, “I am never going to get better,” a caring therapist naturally wants to instill hope. However, as the therapist voices hope, she is taking the positive side of the ambivalence. Consequently, the patient is likely to repeat the negative voice and may even state it more strongly. The power struggle develops as the therapist tries harder to win the argument for hope, leaving the patient to struggle to maintain his lack of hope. There are many strategies that can be used to stay out of these uncomfortable power struggles. In fact I've written a book on this subject.
I sometimes use self-disclosure with my patients; however, I avoid answering direct questions when a projection may be occurring. Lindsay suffered with depression and suicidal ideation. She placed an emergency phone call to me stating that she was suicidal. In our conversation, she was willing to contract for safety. In our next session, she came in looking defensive and somewhat angry. She asked, "Were you mad at me last night - I know you were." To see how I sides-stepped this tricky situation without answering her question directly, read here.
In the case of a client wondering if you are frustrated, this might occur in the form of “either/or” thinking. As in either you were frustrated or you weren’t. You may feel a need to reassure them that you aren't but it's much more powerful to process what it would mean to them if you were or weren't frustrated. In a conversation I had with one client, encouraged her to identify what she would need from herself if I had been mad, and what she would need from me if I had been mad. I never had to answer the specific question which was good because it was actually about something bigger and more important than me.
5. Assuming You Know What's Best (you could be wrong even when it seems
obvious)
A common therapist mistake is to be unaware of how our agendas and values may be impacting the therapy process. Do you think you do not bring your own agendas into therapy? Think again. One of our primary agendas as a therapist is to help people change and we can't help but have our own values about what is best. However, when a person is highly ambivalent, what is best is often very difficult to discern and actually (in most cases) is not even up to us as the therapist. Advice is cheap!
One of our primary agendas as therapists is to help people change. However, if this agenda is too much about you, your values or is presented prematurely, a person with ambivalence may become more resistant to change. Our clients often hold on to narratives and behaviors that, although dysfunctional, feel familiar and even at times, necessary. If you focus your energy on trying to pry them loose because you have an agenda focused on outcome, it may actually feel to the client that you are being insensitive—or worse, simply caring about your own success. Learning strategies which enable the client to find their own wisdom is more likely to "stick."
Validation can be very therapeutic when you are actually witnessing the thing that you are validating: “You have a right to be frustrated that I was late” Or “I see that you are grieving deeply for your loss." But if you aren’t a witness, validate with caution - if at all. A common therapist mistake then, is unknowingly validating a distortion. When people tell us things that someone else did or said, there is almost always a measure of distortion in their perspective. We all distort because we only have our own perspective. Therefore, you really can't believe what you hear.
This topic isn't conducive to a cute cartoon, so I used my sister's art. We often get concerned with questions about whether suicidal ideation is a true desire to die or some desperate attempt to get some form of attention. A dialectic is when two opposing things can exist at the same time. Thus it is possible that a person would want to die when they equally wish for some type of attention, or what I would like to think of as connection. I also believe that most gestures, regardless of how serious or severe, have a communication embedded within them, such as an expression of fear, anger, or feeling misunderstood which needs to be heard. Read here to see how I honored both with one of my clients.
When patients are in denial, it is very tempting to try to get them to see their blindspot. I had a client who was denying her diagnosis and frustrating all parents and treatment team. I could have responded to her by talking with her about her denial of her symptoms, which would have probably made her feel defensive. I would have wanted to point out that she was in a residential program for eating disorders and to explain to her that her insurance company must believe that she had an eating disorder or they wouldn't be covering her treatment. I could even go on and say that in fact, it must be a very serious eating disorder for the insurance company to authorize this level of care. Instead, I chose to be patient, wait for an opening, and then use humor. She related to another person's description of perfectionism and I said to her with a smile on my face, “By the way, perfectionism is linked to developing eating disorders. Not with you I’m sure …just saying.” Go here to read more about this situation.
I’ve always hated to admit when I don’t know something. However, being a therapist has really helped me with this. I’ve been asked so many questions in the therapy office to which I didn’t know the answer and in that process have learned that it’s often times better if I don’t. Trying to come up with an answer or guess at an answer, or even make an astute interpretation may prevent the client from actually working as hard to find the answer that is most right for them to the question that is most important.
My book A Clinician’s Guide to Pathological Ambivalence: How to Be on Your Client’s Side Without Taking a Side can teach you how to avoid these and other common therapeutic mistakes by developing skills to work directly on resolving ambivalence and rewriting old narratives. I would love to hear from you. Please scroll down to the bottom of this page to leave a comment.
And soon to come - the common therapist
mistake of Talking Instead of Asking
