By Alex Fradera

Psychotherapists are devoted to improving people’s psychological health, but sometimes their efforts fail. A new qualitative study in Psychotherapy Research delves into what therapists take away from these unsuccessful experiences.

Andrzej Werbart led the Stockholm University research team that focused on eight therapy cases where the clients – all women under the age of 26 – had experienced no improvement, or in three cases, had deteriorated. This was based on comparing their pre- and post-therapy symptom levels following one to two sessions per week of psychoanalytically-focused therapy for about two years, to deal with symptoms such as depressed mood, anxiety, or low self-esteem.

The seven therapists responsible for these cases (one had two non-improving clients) were also all women, average age 53, with a range of experience in therapy. Each had had success in leading other clients to improvement, which is typical; the evidence shows even strong therapists have cases that fail.

The therapists took part in interviews at the start and end of treatment using the Private Theories Interview – a way of exploring the therapist’s take on the case, how they are approaching it, and (retrospectively) what could have been handled differently.

Werbart’s team used the grounded theory tradition to look for emerging patterns in the interviews and found a paradoxical picture. On the one hand, the therapists talked of the great first impressions they’d formed of these cases; they had a clear sense of empathy with the clients’ plight, and engaged with their interesting stories or quick wits. They also said they had felt a connection, even admiration; these were special cases, and the therapist was motivated to do right by them. They also reported that the clients seemed to be attracted to the process, at least on the surface, finding it intellectually stimulating.

Yet the therapists also reported that from the very beginning there was a sense the clients were somehow removed. This was the first inkling of what Werbart’s team found to be a key theme, of “having half of the patient in therapy”.

Initially the therapists said they were optimistic that this was a solvable challenge, but as the sessions continued, it became a mire. Whenever the therapists attempted to address what a client was not disclosing, the client would typically pull back – by intellectualising around issues, or holding back revelations until the session was nearly over. Later, some clients became impersonal in manner and treated the therapist as just a part of the furniture, or they cancelled sessions entirely. The therapists described how trying more actively to wrest back control led to “fruitless battles”, and the process terminated with the therapist in an emotional state, overwhelmed by the client’s energy. One therapist reported “I felt I was drawn into some damned depth.”

Werbart’s team speculate that the paradoxical elements – high initial promise and enthusiasm followed by the later sense of distance – may form two parts of a whole, the case of a therapist “one-sidedly [allying] herself with the patient’s more capable and seemingly well-functioning parts.” These clients are clearly sharp, and may have developed shiny, effective defence mechanisms that took the therapist in. Evidence shows that therapists who initially underestimate the degree of the client’s problems are more likely to struggle, and that successful outcomes begin with a good reading of the situation, not sceptical, but not credulous either. Regarding the current cases, the therapists may have been beguiled by their client’s charisma, and were on the back foot when they belatedly began to dig deeper.

Despite acknowledging the lack of improvement in their clients, the therapists maintained that the therapy they’d offered had been useful – that their clients had grown in self-awareness, laying groundwork for improvement, if only there were more time. While this interpretation can’t be ruled out, the therapists’ insistence on it may reflect a reluctance to acknowledge their being taken in by their clients’ defences. This is perhaps because being a therapist – especially in ultimately successful therapy – is associated with unpleasant feelings, as progress means getting into hard and upsetting issues. A rare case that generates strong feelings of engagement, connection and excitement – even in the absence of tangible improvements – may feel like a welcome change, and it may be hard to acknowledge that the such situations are not cause for celebration, but for caution.

“It was like having half of the patient in therapy”: Therapists of nonimproved patients looking back on their work

Alex Fradera (@alexfradera) is Staff Writer at BPS Research Digest