Psychotherapy works for most people, but there’s a sizeable group for whom it’s ineffective, or worse still, harmful. A new study claims to be the first to systematically investigate what the experience of therapy is like for clients who show no improvement after therapy, or who actually deteriorate.

Andrzej Werbart and his colleagues conducted in-depth interviews with 20 non-improved clients (out of a larger client group of 134) who were enrolled in individual or group psychoanalytic psychotherapy at the former Institute of Psychotherapy in Stockholm. Seventeen of these clients showed no symptom improvement after an average of 22 months therapy, and three showed deterioration. The clients’ had an average age of 22 at the treatment start, and 17 of them were female. Their problems included mood disorders, relationship problems and self-reported personality disorders. The interviews took place at the end of the course of therapy, and then again one and half years later.

The researchers transcribed the interviews and identified a key central theme: “spinning one’s wheels” as exemplified by this client quote:

“When I think back on the therapy, I get the feeling that I often sat and talked; sometimes something important came up, but often it felt like it was pretty much just spinning my wheels.”

What other messages were distilled from the interviews? The clients had largely positive views of their therapists, but they saw them as distant and not fully committed. A recurring issue for the clients was feelings of uncertainty over the goals of therapy and the methods to achieve those goals. Many had expected a more challenging, confrontational, structured style of therapy.

The researchers said the 16 therapists (10 female; average age 53), many of them highly experienced, who’d worked with these non-improved clients, may have been guilty of sticking too rigidly to traditional psychoanalytic technique:

“The patients’ descriptions of therapists’ silence and passivity together with a focus on childhood experiences and deep roots of presented problems resemble a caricature of psychoanalytic psychotherapy, but unfortunately the picture may be accurate,” they said.

The researchers urged therapists to address their clients’ treatment preferences and expectations – such reflection could have led to the realisation that a more “directive, task and action-oriented” form of therapy may have been more appropriate for these clients (conversely, other research has found that dissatisfied CBT clients tend to say they would prefer an approach with more emphasis on reflection and understanding). Clients need to be involved in setting the goals of therapy and educated about what the process will entail, the researchers added. But also, “the therapist needs to learn to be the unique patient’s therapist.”

Previous research has already established that therapists are poor at identifying when therapy is not working. Werbart and his team said that “formalised feedback” based on client surveys during therapy “can be a less threatening way to start discussions on negative and hindering therapy experiences.”

On a positive note, between the end of therapy and later follow-up, more than half the non-improved clients showed beneficial decreases in their symptoms. Such ongoing change was not observed for clients who showed more immediate improvements after therapy, suggesting these changes were not a mere consequence of maturing. “Rather, the conclusion is that non improvement at [therapy] termination does not imply lasting symptoms,” the researchers said.

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Werbart, A., von Below, C., Brun, J., & Gunnarsdottir, H. (2014). “Spinning one’s wheels”: Nonimproved patients view their psychotherapy Psychotherapy Research, 1-19 DOI: 10.1080/10503307.2014.989291

—further reading—

When therapy causes harm

The mistakes that lead therapists to infer psychotherapy was effective, when it wasn’t

What clients think CBT will be like and how it really is

Post written by Christian Jarrett (@psych_writer) for the BPS Research Digest.



