What can clients do to increase the chances that therapy is helpful?

One of my favorite DBT assumptions is "People may not have caused all of their own problems AND they have to solve them anyway."

I've seen a lot of posts lately about the problems of therapy and therapists. I am not denying that those problems are there. Not all therapists are competent and not all of them are ethical. I have also been deeply hurt by therapists in the past. And some of the stuff they said and did was wrong. Many of us were victims of abuse or neglect as children too. And I believe that one of the processes of healing from that is a transition from a mindset of helpless victim (which we were) to competent adult (which we can become.)

So in that vein, is there anything that you have done within the therapeutic relationship to make therapy more effective for you?

Yes - I made the one I hired stop talking. I never found her input useful and when I would ask her what the point of what she was saying was, she always said she did not know. So if I didn't know and she didn't know- there was no point to let her keep talking. It did not make her helpful but it did make her less unhelpful.

For me, I walked in with a determination that I was going to walk through whatever fire I needed to in order to get past my issues that were continually bogging me down. I hadn't really done that the first couple times I engaged in therapy; the last time I went in with a different goal and stronger determination toward change. I committed to attending regularly, speaking up and diving in even when I really wanted to clam up and avoid those hard topics. I committed to getting real with myself and being willing to hear where I was habitually making the same errors that were keeping me stuck AND practicing changing those habits (and for me, they were definitely habits of thinking, feeling, and behavior). It was not easy to face those realities about myself; I would have rather made someone else responsible for my misery. But the reality is that no matter what had happened to me in the past that WAS someone else's fault, my present IS my responsibility -- no one can fix how I deal with my present but me.

I give my T lots of feedback. I let him know what he's told me that I've found helpful and what has been less helpful in the moment. If he says something that hurts me (however unintentional), I let him know. If his approach isn't helping me--whether overall or just at that particular time--like needing support vs. wanting more honest feedback/devil's advocate--I let him know. When I've had doubts about the relationship, I consulted with another T (a couple times). When I had serious doubts recently and thought we may have hit an impasse, I tried to discuss it with him, then opted to terminate briefly (OK, it ended up more brief than I'd intended) and saw another T for a couple sessions and also contacted a few others. I opted to go try talk things through more with my current-again T, assessed what had gone wrong over the summer and what had contributed to that, and we're both trying to make sure we understand each other.


May write more later, but really--giving feedback, standing up/advocating for myself, etc.

I agree with this a lot. When I first started therapy I would get really, really angry at the therapist, but because of my own fear of anger in myself and in other people I would "express" that anger by refusing to talk or other non-verbal passive aggressive behavior. This was not effective at changing her behavior because she had no idea why I was angry. I still get very angry at therapists...after all they are poking at my vulnerable areas. But now I know that I can communicate that to them directly and effectively and that works better.

I also reinforce them when they do something I like or is helpful to me. Behavioral principles work both ways. For example, if they ask me questions and really understand a problem before trying to fix it, I like that much better than a bunch of random advice. So when they do what helps I tell them emphatically how helpful that is to me. It makes them more likely to do it again.

For me, it is taking ownership of my life and doing what I need to do in order to heal. I have come to realize that nothing T says will fix my situation. Her support and help is very important but unless I am willing to be vulnerable and honest and willing to trudge through the mud. my life will not change

If I may ask a question:

I hear a lot of how the client needs to take ownership of their own problems and be willing to face painful truths and all that. But as a therapy client, how can you tell the difference between that and a therapist just leading you astray or pushing you to take on false responsibility?

I ask because these are very much the things I was hearing when I had problems with therapy. And in retrospect the problem was the therapists I was seeing were trying to get me to face painful truths that weren't actually true. They were trying to get me to realize that things weren't as bad as I was seeing them and that I did have a lot of control over the situation, at a time when what I needed to face was that things were way, way worse than I was seeing and I had no way to affect the situation at all other than by getting myself the heck out.

But that is really only clear in hindsight. To me at the time, it was just a confusing mess where I had nightmares that didn't seem connected to anything and generally felt horrible in ways that didn't appear to be connected to anything at all. It always seems like the first thing the client needs to do in order to make therapy helpful is to have a thorough understanding of their own problems, be able to determine what steps will and won't fix them, and know how to clearly communicate that to a third party. Which rules out a lot of the reasons people go to therapy!

So how do we help the client who's in a position of "I don't understand what's happening; I just know that I feel bad and I really don't know why I feel bad" be able to engage in therapy safely?

I'm sorry you had that experience. I guess for me the way that I can tell if a therapist is being unhelpful or even hurtful is if I constantly feel worse after a session. Then I try to calm down and determine exactly what he or she said that made it worse. I have gotten much better at that over the years. My first therapist was harmful, ironically in the opposite way that you have experienced--she exaggerated my trauma and I started to feel a lot more sorry for myself rather than healing from it. It also caused problems with my mom because the therapist said she was to blame for some of my stuff.

It did take awhile, but I figured out that she wasn't correct. Each time I have a bad therapist after that first one I figure it out sooner. And because of my relationships with bad therapists, I learned how to stand up for myself, which is a skill that has translated somewhat to other relationships. So it wasn't all horrible.

1. Take responsibility - for their lives, decisions, actions, behaviours. And not put all responsibility on T's shoulders.

2. Ts are not mind-readers. I am guilty as charged here.

3. Work to change ourselves not pressure T to change by making demands, expressing anger and/or some sort of emotional blackmail.

I'm sorry you've had that experience.

I've never had a therapist try to say what happened to me wasn't actually as bad as I thought it was. In fact, probably more what I experienced is that I had minimized what had happened to me and they were working to help me see how serious an impact my experiences had had on my life and to place the responsibility firmly in the right place rather on myself.

When I speak of taking responsibility or ownership, I am talking about my present. I am also talking about my own thought processes and the emotions and reactions that come from those, not the actual circumstances. Actual circumstances are actual circumstances. Crap happens and we can't necessarily fix the actual problem. What I DO have control over is how I choose to internally deal with whatever is happening in a given moment.

When I go into the mindset that outside physical circumstances are in charge of my emotions, then I've lost control internally. I become overwhelmed. I become anxious. I fall into depression. I don't have to do that.

Lately, my life and the lives of loved ones around me has been crisis after crisis -- seriously difficult times. And I found myself doing just what I described in the paragraph above, mostly because of my thinking about this perfect storm of colliding crises whirling around me. I finally, just this week, took the time (yes, it takes me deliberately working at this) to sit still and regroup, particularly regroup in the way I was thinking about what has been going on. I'm starting to feel centered again. My mood is lifting. My anxiety is lessening.

1. In the area one is working on, do the opposite of what the patterned behavior is when interacting with T.

2. Listen as best as possible to what you feel you need when it comes to a therapy modality.

3. Be willing to leave if needed but not leave just because it has gotten hard.

4. Be willing to look at multiple avenues and supports to improve your mental health and skills.

5. Accept that some things are just who you are as a human and that is ok - no need to change, judge, or analyze them.

The participant needs to buy into and commit to the therapy. They need to do the homework they are given and actually heed the advice of the therapist and try some of the coping suggestions being made. Just going back and forth to the therapist and talking will result in little headway. One has to actually listen to the therapist and do the work. If you are doing so, you need to stop fighting against the suggestions made. Too many expect the therapist to fix them, we fix ourselves with the aid of the therapist. Listen. Make the commitment. Work hard.

I have never met a client who "expected the therapist to fix them." I think that is ridiculous. I think that profession does its best to keep information on what is supposed to happen and how it happens mysterious and opaque so that the client is put in a one down position. Therapy can fail no matter how hard or committed a client is. As for buying in - I would never suggest buying in to what you do not understand.

You don't have do anything. You either FIND it helpful or you don't.

Now you have met a client that has done exactly that. I have absolutely gone into therapy expecting the therapist to say the exact right thing that would make me feel better, despite me not really knowing what it was, and despite not particularly wanting any advice.

I agree with not buying into something that you don't understand. I make the therapist explain it. And there are certain kinds of therapy that I won't touch with a ten foot pole. But I think there are types that I have dismissed too fast because they sounded "stupid," that might help.

I also agree that sometimes therapy can fail despite the client's best efforts. I think that some therapists abdicate responsibility by blaming it on the client. If a person dies of cancer after being treated with chemotherapy we don't say that she "failed at cancer treatment," we say "the treatment failed." And at the same time if the person skips every other treatment she hasn't maximized her chances of the treatment succeeding.

I disagree that "the profession" tries to keep things opaque in order to have power. The profession isn't that organized. There are just too many types of therapy and ideas about how to do it. The training isn't consistent and the outcome studies (even the best ones) aren't that conclusive.

Since both CBT and psychodynamic therapy failed for me, I'm trying DBT. I do like how transparent and straightforward it is. And I like that one of their main assumptions is "Clients cannot fail at DBT" and another one is "Therapists can fail at delivering treatment and the treatment can fail."

Well, disagreement is one of the spices of life.

What I mean here is that, at the time I was in therapy, I was in fact currently at least partly in an abusive situation. But one that I'd been told all my life was normal. So "taking ownership" was ending up just meaning taking responsibility for not being able to put up with abuse with no emotional reaction.

It gets into a lot of other things too. Like, I understand that therapists aren't mind-readers. But the client isn't always the expert in a way that they can know and recognize all the relevant information and clearly present it to the therapist. They also might not (this was also big for me) have the skills at the time to do what the therapist wants. I feel like I got wrongly labelled as not putting forth the effort a lot because of that.

I always felt like all the things that you're supposed to do in order to get therapy to succeed were basically the exact things that I went to therapy because I didn't know how to manage them on my own. Like if I could have gone in, told the therapist exactly what was going on and why, and then taken home assignments on my moods and filled them out and brought them back and identified issues - I wouldn't even have gone to therapy if I could do all that!

That's kind of my question here. So much of what's suggested seems to me to amount to "don't have any problems other than basic depression or anxiety if you want therapy to succeed." How do we avoid that?

For me is appreciating the authenticity of who the therapist is, to determine whether or not the therapist and his/her modalities are a good fit for me, to walk in prepared with what I want to speak about and an open mind for feedback (which I can always see if the feedback is working for me or not), to not see one sole therapist as an end-all (I can find other therapists if this one isn't working out, or if this one can only address one issue for a short time, and when that time is over, I can move on to the next one), to try and be honest in areas that I am ready to talk about (I can set the pace of the therapy, especially since trying to move too fast in therapy for me, or disclose things I'm not yet ready to tell, has NOT worked for me in the past), to come up with my own set of boundaries for the therapeutic relationship (e.g., such as expressing my needs and expectations, including consistency in the relationship and clear treatment goals with risks addressed), and to ask specifically what the therapist's credentials are so that I am aware of what the therapist might not be able to work with me on. Before sessions, I try to prepare in advance by figuring out what I plan to talk about (those plans sometimes get changed abruptly in therapy, and I have since learned to assess whether or not the therapist is aligned with my goals for that particular session, and to discuss when our goals seemed to be unaligned for that session). What works is knowing what I want out of therapy ahead of time, and if I don't know exactly what I want out of therapy, I'll ask what the options are. When I see red flags, I question and arrive at a conclusion on my own to continue or terminate. When I say that I want to process trauma, discuss some hard things, express emotions without abrupt interruptions (even though some interruptions are necessary), and move forward from the treatments I've had in the past, instead of being stuck in regurgitating the treatments I've already had, then I expect a professional understanding of that need. If I don't get what I'm looking for, I simply move on and not waste time or money. It's as simple as that for me. The therapist either knows or knows how to probe for clues as to what would best help me, or the therapist doesn't.

I think for one thing you find a therapist that doesn't specialize in basic depression and anxiety. I'd look for one who specializes in difficult to treat problems like borderline personality disorder or complex PTSD. Most likely the first time you went to therapy you didn't know that there was much of a difference between therapists. I certainly didn't. But now we do. Also since the time you and I both went to therapy the first time there have been some changes in the available strategies. It's gone from lying on a couch talking about problems , to filling out worksheets on thoughts and emotions, to EMDR, body work, and mindfulness training.

This is a simple thing but journaling after every appointment has helped me. I write about my feelings and everything we discussed. This helps me make better connections and internalize some of the things from the session.