Dealing with therapy failures/clients that don't improve or get worse

[Rivi]

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[docma]

As a field I think we have not done very well at studying this area and only recently (and I can't recall exactly where) have I seen some good published work on the topic of "deterioration" as an understudied element of therapeutic work. Of course it happens and we are often to quick to name and blame ("resistance" or "treatment failure" when we don't have the "mechanism of action" at all sorted out). Certainly as a beginner who is still getting supervision you should bring this topic up so you can get a balanced view of the fact that deterioration does happen. We all need to be alert to tendencies to feel we should be omnipotent or hyper-responsible. We need to do our best and sometimes that is not enough. Of course you want to look for what you could have done differently or might learn from circumstances like these. But good supervisors will help you do that.
Treating addictions (and eating disorders have many parallel elements) is often an up and down and long term course so learning what you can about the process of change and motivational interviewing may help with understanding the course of events. I also think behavioral and systems perspectives are very useful in getting perspective

 

[deleted176373]

Don't work with PD's then.... at least not until you get a thicker skin about treatment failures. While certainly you should examine your treatment decisions and approaches in a healthy honest way, you are not responsible for the treatment success or failure of a client.

One supervisor put it this way for me: "You don't control the outcome, you are simply not that powerful." As soon as you start believing that you control a client's behavior you have crossed a line that is no longer therapeutic and is manipulative, or at the very least arrogant and unfounded.

The sooner you admit to yourself that you will never "cure" anyone, the sooner you'll feel better about the outcomes. You'll find that in many cases you can make a difference, when you cannot, refer to someone you believe can make the difference. That is the ethical thing to do, and it sounds like that is exactly what you did do. Do not place a value on treatment outcome, but do place a value on delivering treatment competently, you can do everything right and still end out with a horrible treatment outcome.

Do not make treatment outcomes about you... it will drive you nuts. Now tell us, how powerful are you? Is your Kung Fu better than mine?

Mark

 

[stigmata]

All of this is out of your scope of therapy skills, that is because you are in training are not a qualified provider yet. You will be, and will learn that many people only want to feel better, not get better, and this is not your failure. BTW, a psychiatrist alone is not better care by any means.

 

[Therapist4Chnge]

Well said Mark.

Your esteem as a provider should not be tied to your patients' successes/failures, as failure happens for many reasons outside of your control. As someone who worked with EDs for a few years (and many PDs), it definitely takes thick skin. I'm sure you'll fail many times, just like every other provider, which is why when a patient improves their life it is meaningful.

 

[Neuropsych2be]

Actually you can not gauge the success of your therapeutic skills until your clients die! Seeds you plant now may not come to fruition for a long time. Much of the progress clients make in therapy occurs after the termination nof treatment as insight is slowly used as a template for change across time. In many ways good therapy is a recapitulation of development and much of the regression you are seeing is a natural part of therapy as defenses come down. I would suggest that you look at the quality of the therapeutic relationships you are developing. Despite everything you may read on SDN, relationship variables and other common factors are the heart of therapy. You may also wish to ask yourself if this is a counter-transference reaction on your part. This is clearly an issue you should discuss in supervision if it is bothering you enough to bring it up on an internet forum.

 

[zzzz2]

Also, I understand that it is normal to have clients that don't improve but I still have a hard time not blaming myself on some level for this. It definitely hurts me on some level because I know that I could have done better and that I could have handled some clients more skillfully. I was never a "natural" at counseling and I think that part of me still feels insecure doing this process despite the fact that I am no longer "new," or at least brand new.

I think as professionals in training we have to be careful about not making our self-esteem and insecurity get in our way. You do your best in therapy not because "success" or client improvement makes you feel better about yourself (it is a byproduct, for sure), but because you know your client might benefit from therapy. It's natural and important to ask whether you could have done more. It's even more important to ask whether what you have done was the best given the circumstances (e.g., difficult clients).

 

[Rivi]

Thanks everyone that is helpful.

 

[stigmata]

As soon as you forget about the client stuff, and realize that people who seek help for mental health reasons are patients deserving of the same respect as those with common physical health problems you will do better, as will your patients.