Therapists Can Be Wrong

Therapists, like many professionals who work directly with clients, need to present themselves confidently in order to be effective, even when they’re not feeling very confident. It can be difficult for therapists to admit that they have or could be wrong, or that they don’t know everything. Like doctors and teachers and others, therapists worry that acknowledging their own limitations will erode their credibility and trustworthiness. When your livelihood depends on people finding you credible and trustworthy, that adds to the aversion of being wrong and admitting mistakes that virtually all of us already experience.

Yet we have to learn how to admit and accept that we are sometimes wrong–not only because it’s a foundation of accountability and ethical practice, but also because clients can often see through that facade, and they won’t like what they see. It’s difficult to trust someone who will never–can never–admit that they’re wrong.

This was going through my mind as I read one of my required texts for school, Psychiatric Interviewing: The Art of Understanding“Psychiatric interviewing” is really just a term for the process of therapists asking their clients questions, so the book covers a lot of very important ground. While I’ve found it useful so far, a few things irk me about it.

For instance, the author has a strange preoccupation with labeling clients using the article “the” in a way that implies uniformity. The text is laden with references to what “the paranoid patient” may do or how “the guarded patient” may behave in an interview. This type of language is not only dangerously vague (who qualifies as “the paranoid patient” as opposed to “a person who has some paranoid thoughts”? Who gets to make that determination, and using which measure(s)?), but stigmatizing to therapy clients and a potential source of bias for therapists. If you’re a young therapist who reads this book and gets all these ideas about what “the paranoid patient” may do, you may project these assumptions onto every client you work with who struggles with paranoia or expresses thoughts that seem paranoid to you. Assumptions are not necessarily a bad thing–and may even be useful in some cases–but you need to be aware of them as you work. Thus far in my reading of this book, it has not provided any cautionary notes about making assumptions. Even in my classes, in which we are often told not to make assumptions, provide little if any guidance on learning to actually notice these assumptions in practice.

Shea also recommends a few other techniques that I find excessively presumptuous. Take this example dialogue from the book:

Pt.: After my wife left, it was like a star exploded inward, everything seemed so empty…she seemed like a memory and my life began to fall apart. Very shortly afterwards I began feeling very depressed and very tearful.

Clin.: It sounds terribly frightening to lose her so suddenly, so similar to the pain you felt when your mother died.

Pt.: No…no, that’s not right at all. My mother did not purposely abandon me. That’s simply not true.

Clin.: I did not mean that your mother purposely abandoned you, but rather that both people were unexpected loses.

Pt.: I suppose…but they were very different. I never was afraid of my mother…they’re really very different.

A lot of therapists, especially those in the psychodynamic tradition, are understandably attracted to the idea of making this sort of “insight.” As Shea points out, when you get it right, it can build a lot of trust because the client feels understood in a very special way. It feels good to feel “smart” and insightful, to be able to read people like that. It can remind us that there really is something special we can do as therapists that others cannot. It probably doesn’t hurt that this, the therapy-via-Sudden-Brilliant-Insight, is usually the only kind we see represented in the media.

But a lot of the time, there really isn’t enough information to reach this conclusion. Therapists may make these leaps based on hunches, but that doesn’t mean there’s data to back it up. Sometimes the client will tell you so, but I think that a lot of the time, they will say, “Hm, I suppose you might be right,” because you are an authority figure and they want to believe you have the answers.

From the information given, you can’t reasonably jump to the conclusion that the client felt similarly when their wife left them and when their mother died. Those are very different types of loss, and even similar types of loss–two breakups, two deaths in the family–can feel very different.

Certainly there can be conceptual similarities between losing a spouse to divorce and losing a parent to death. It might even be worthwhile to explore them, but the therapist need not assume they felt “so similar.” If I were the client, I would’ve liked the therapist to say something like:

Between this and your mother passing away, it sounds like you’ve been dealing with a lot of loss. I’m wondering if losing your wife is bringing up any memories of losing your mother.

This resonates with me; it might not with other clients. That’s why sometimes the more important thing as a therapist isn’t what you say, but how you respond once you realize you’ve said or done something that strains the connection between you and your client. In this case, a responsive therapist might say something like:

I’m sorry, I didn’t mean to make assumptions about how you’re feeling. Can you say a bit more about how this loss feels different for you?

The client is the expert on their experience.

But instance, in the dialogue, the therapist doubled down on the (mis)interpretation, attempting to justify their response to the client’s disclosure. This leads the client to double down as well, justifying to the therapist why the losses feel different. They shouldn’t have to justify themselves that way.

Here is the thought I had, as both a provider and a consumer of mental health services, when I read Shea’s example dialogue above:

The failure mode of Brilliantly Insightful Therapist is Arrogant, Presumptuous Therapist.

Now, I don’t know if Shea is arrogant or presumptuous; I don’t know him but I would hope he isn’t. I do know that refusing to acknowledge missteps and misunderstandings can lead one to across that way, though. And that’s exactly what Shea refuses to do both in the dialogue itself and when he analyzes the dialogue for the reader:

Needless to say, this attempt at empathic connection leaves something to be desired. The patient’s attention to detail and fear of misunderstanding have obliterated the intended empathic message, leaving the clinician with a frustrating need to mollify a patient who has successfully twisted an empathic statement into an insult of sorts.

This probably infuriated me more than anything else in this text. Here, the failure of the interaction has been blamed entirely on the client. Shea has assumed that the client has taken his statement as an “insult” when there is no evidence of this; the client is merely correcting the therapist’s misinterpretation. It reminds me of how, often when I tell people they’ve made inaccurate assumptions about me, they respond by shrieking about how “upset” I am and how I take everything as an “insult.” Correcting someone is not the same thing as being “insulted.”

If this situation is “frustrating” for the clinician, then, I can only imagine how much more so it must be for the client.

There is no room, in this approach, for any acknowledgment that the therapist’s interpretations might simply be wrong. No room for the possibility that it’s not the client’s personal characteristics (“paranoid,” “guarded,” “histrionic”) that made this interaction fall flat, but the therapist’s presumptions and subsequent refusal to step back from them.

I discussed this particular example because it’s what came up in my reading, but it’s hardly the most egregious thing of this type that happens. Therapists who cannot conceive of the possibility that they’re wrong not only fail to help their clients, but can actually hurt them.

Since there are probably a lot more therapy clients (or prospective therapy clients) reading this than there are therapists, I want to be clear about why I wrote this. It’s not to discourage people from seeking therapy, but to arm them with the knowledge and language to advocate for what they need from their therapists, and to find therapists that suit their needs.

That last part is important. Some people may want a therapist who makes bold interpretations and takes that authoritative, explanatory sort of role. Personally, I think conducting therapy in this sort of way opens practitioners up to all sorts of bias and errors, which is one reason I want to avoid it both as a client and as a therapist. But if that’s the approach that resonates with you, then it’s likely to work a little better for you, because the most important factor is the client-therapist relationship.

Aside from that, the reason I write about problems in mental healthcare is the same reason I write about problems in feminism or atheism–to hold my own communities accountable. Anecdotally, I know that this sort of thing makes it difficult for some people to benefit from therapy, or even to want to access it to begin with. I’m not the only person who dislikes having an authority figure tell me things about my life without bothering to find out if their assumptions are even accurate.

I trust people more when they admit their mistakes.

 

{advertisement}
Therapists Can Be Wrong

19 thoughts on “Therapists Can Be Wrong

  1. 2

    The text in the book actually scared me. I’m not a therapist, but I’ve known a lot of people who had/have weak senses of identity. In such a case, acting like an authority, when the clinician is wrong, could be abusive and dangerous, I fear. Suppose a person who didn’t trust themselves and their own thoughts is told something that feels a bit wrong but won’t speak up. Now the client will second guess themselves even more and feel alienated from their own thoughts, almost as if a second voice is taking over. At least, this is what I fear.

    1. AMM
      3.1

      Me, too.
      .
      The former therapist in my case was in many ways very helpful over the years, but she tended to assume that if I didn’t adopt or agree with her insights, it was me resisting therapy. There came a point when I had mostly overcome the problems she could help me with, and wanted to use therapy to learn more about myself, and I began to find her “insights” more intrusive than helpful. Whether she was right was irrelevant. Basically, I got to the point where I felt I couldn’t talk to her about anything meaningful.
      .
      When you’re talking about relationships, if you have a disagreement, being right is often more harmful than being wrong.

  2. 4

    I think an average cold reader would not make these interviewing mistakes in the examples you give. A cold reader will not ride a hypothesis very far in the wrong direction and will quickly dismount without apology or explanation.

    You wrote:
    ” It reminds me of how, often when I tell people they’ve made inaccurate assumptions about me, they respond by shrieking about how “upset” I am and how I take everything as an “insult.” ”

    I know there is little context here and I assume that they do not literally shriek but if they are getting upset when you correct them it may be useful to look for better ways to make that correction. There are many ways to react and or respond when someone makes an inaccurate assumption. Best is one that lowers the tension, one that doesn’t directly contradict, that can come later if at all. For example, “Hmm, I’ll have think about that” or “I didn’t know people were getting that idea about me” or “How am I giving out that impression”?

    The thrust of your article is that one should be open to criticism.

    I think I would have trouble with many pages of that text book. What you have quoted seems so pre-1950 to me. Of course if it’s an intake or initial evaluation interview it just about requires a kind of interrogation and trying combine that with actual therapy is probably impossible to do well. In the quotes the interviewer seems to be gathering information for diagnostic purposes, while at the same time claiming to be empathic and doing therapy. He uses the term, empathy, in an odd way as if it were a technique to be turned on and off. “The patient’s attention to detail and fear of misunderstanding have obliterated the intended empathic message, ” An intended empathic message? Empathic is something you either are or are not in any moment, not a message you can send. Most interviewer responses are, in fact, not empathic at all, but rather interpretations of what he has heard. If anything will engender mistrust in a client or anyone else for that matter, it is fake empathy.

    1. 4.1

      So if people are upset with Miri because she corrected them for their false assumptions about her, then she should avoid correcting them?! Shouldn’t they learn to be more open-minded to criticisms of their assumptions and ideas? Why does she have to be the one her behavior when the fault lies in them?

      1. Meetup,

        Because Miri is in charge.

        She is in charge of herself and she is in charge of how she wants to relate to the others. She can decide which of her repertoire of behaviors she wishes to present to the others.

        She can decide to be more thoughtful in the interaction than the others. She can decide to allow them as much leeway in their behavior towards her as she wishes. She can set limits (they are friends), I will listen to this but not that.

        My suggestion implied that she invite/permit them to tell what feeling arise in them in her company, within limits of course. She can decide to tolerate some initial discomfort. with the expectation of learning something useful about her impact on others.

        She can, by her example, be teaching them ways of interacting that may be new and /or useful to them. Her example of being in charge may provoke them to try to correct that behavior, but that may serve to stimulate further useful discussion.

        Another way of being in charge is to notice that one can direct one’s attention. In my interaction with you I can focus on my reaction, my feelings, or I can pay attention to what I think is going on with you. (and I can check that out with you if it’s ok with you to do that.) And I can alternate that focus back and forth between us. If, say, a negative feeling arises in myself, I can shunt it aside for later, and turn my attention back to you. I don’t have to react to anything instantly.

        1. As interesting as this segue is, I’d like to ask that it end here as it’s quite off topic. I can discuss my personal behavior, which I assure you I’ve put much more thought into than you seem to think, with people I know personally. Here I’d like the discussion to focus on the subject of the post.

  3. 5

    You’re note that “The failure mode of Brilliantly Insightful Therapist is Arrogant, Presumptuous Therapist.” is very similar to something John Scalzi said. I assume you’re intentionally referencing him. (Or is there some older idea you’re both instantiating?) For those who haven’t seen it, Scalzi had an excellent piece stating that “The failure mode of clever is ‘asshole’.”: http://whatever.scalzi.com/2010/06/16/the-failure-state-of-clever/ (Heck, I think Miri’s version is even a strict subset of Scalzi’s.)

  4. 6

    Excellent analysis. This is so much of what can go wrong in therapy: therapist is responsible for successes, client for failures. And as ludicrous @4 says, not far from cold reading.

    It occurred to me that in the context of a some-what trusting therapeutic relationship, such ruptures can actually be beneficial, if they expose relationship patterns and can be processed meaningfully. So if the client has had issues with significant others misunderstanding them as the therapist has, this could actually be an opportunity to work on that. But it would have to start with the therapist admitting they were wrong.

  5. 7

    I see the main thrust of your OP as directed to the conduct of the therapist confronted with the reaction of the client. The therapist should be ready to acknowledge that her interpretation is wrong – that’s the main upshot. Nothing to quarrel with, to be sure. This is important indeed.

    I was wondering about this fragment:

    I want to be clear about why I wrote this. It’s not to discourage people from seeking therapy, but to arm them with the knowledge and language to advocate for what they need from their therapists


    because here the emphasis shifts: in this passage it is the client who is primarily viewed as playing the active role (“armed with knowldege”, “advocating”). I would be interested in hearing from you a bit more about this, but in terms of a practically oriented advice: what sort of language would it be (in your opinion) advisable for the client to use in the sort of situations you describe? Also: what sort of knowledge did you have in mind and how exactly could the client use it in practice to make the client-therapist relationship more successful?

    Some loose thoughts now. I was reading the OP thinking all the time how universal it is – how it applies (almost without changes) to all sorts of situations, going far beyond the therapist-client relationship.

    Some people may want a XXX who makes bold interpretations and takes that authoritative, explanatory sort of role. Personally, I think conducting XXX in this sort of way opens XXXX up to all sorts of bias and errors, which is one reason I want to avoid it


    This indeed resonated with me. I’m one of those with a very ambivalent attitude to such people. My immediate reaction is to protest, kick, and scream; but I can’t deny the ‘paradise lost’ feeling hiding somewhere in the background – this childish yearning for someone who is wiser and who will just tell you who you are and what to do (in practical life, mind you, not in theoretical discussions – in the last area I’m strangely immune). And yes, I know how it sounds.

    (Hmm, this inner conflict has always been quite real for me and eventually I saw no other way of resolving it than simply marrying such a person.)

  6. 8

    This article has really gotten me to think critically about this issue, especially since I’ve received multiple times that form of psychotherapy for my depression and social anxiety disorder. Of course, insight-oriented therapy have never worked for me and it has been such a negative experience for me, that I’ve decided to avoid it altogether! I’m currently taking antidepressants and I run a discussion group on depression and anxiety disorders that meet biweekly.

    Another major pitfall that insight-oriented therapists in particular fall into is their avoidance in taking a scientific approach to their practice. I don’t just mean reading the scientific literature regarding psychopathology, its treatment, etc. What I mean is that all insight-oriented therapists ought to realize that their “insights” about their clients are hypotheses that should be tested (and also to ask themselves if their hypotheses are even falsifiable and thus, testable to begin with). In addition, it would involve being more attentive to the facts and more flexible in their hypothesizing and theorizing.

    For instance in the dialogue above, the clinician’s “insight” (expressed as a mistaken empathic response) is simply a hypothesis about why the patient reacted intensely negative to his wife leaving him. If Shea had a more scientific mindset (and, lets face it, more modesty), he would have acknowledged that the clinician got it wrong, but in the process gained a very important information: the patient had feared his wife while he didn’t toward his mother. With this, the clinician should modify or even discard their “insight” and form a new hypothesis that takes this valuable info into account. But instead, Shea was too attached to the clinician’s “insight,” being inattentive to this new info, and criticizing the patient for being resistant to this “insight” (isn’t that a shocker[/sarcasm]).

    However, while I believe being scientifically oriented in psychotherapy is necessary to avoid such scenarios, I don’t believe it’s sufficient. I’m thinking of Richard Dawkins…

  7. 10

    Alright, I admit that Shea is failing to take responsibility for his own missteps in the last block quote. But in the client-driven MHP models in which I’ve been trained, sometimes it’s really goddamn frustrating when Client/Patient X are supremely passive and expect you to do all the heavy lifting, especially when mental health is integrated into other services,like the pursuit of housing or employment. All about the client and the client’s needs at the client’s speed,yadda yadda yadda. But then why would nothing be the client’s fault when Client X is being obtuse or stubborn? The client in the OP example is not particularly obtuse, but I refuse to free clients as a class from all responsibility for their actions, especially when it comes to addiction. (I read the Alternet essay you linked to the other day in your feed).

    1. 10.1

      @Lucky Latke: I don’t actually think we should “free clients as a class from all responsibility for their actions,” and I don’t think I implied otherwise. However, there’s a difference between what the therapist thinks or writes in their progress notes and what they communicate to the client. Assigning blame is rarely productive for therapy. In situations like you describe, motivational interviewing is a great evidence-based approach that aims to engage clients who may be unwilling/uninterested in changing so that they formulate their own motivations for change and then act on them. MI was actually developed with substance (ab)use issues in mind, but it’s useful in a lot of situations. Labeling clients “obtuse” or “stubborn” is not part of it, and it wouldn’t help at all.

  8. 11

    What I liked about my therapist was that instead of making assumptions, he was asking questions.
    I think in retrospect that a lot of the questions he was asking led me to those points where he thought my issues lied, but it was me going there.
    I also remember that he carefully inquired about subjects that in the end were not relevant, such as if I’d been a victim of heavy sexual assault, so he obviously wasn’t a mind reader.
    About being wrong and losing credibility: For me, somebody who can say “I’m sorry I was wrong” is way more credible than somebody who insists that they’re not in the face of evidence pointing to the contrary. One of the professions you mention in the beginning is a teacher, which is my profession. Back when I was a student myself I did not respect teachers who made mistakes and could not admit them. I could see this mistake, I knew they were not perfect all-knowing overlords. If they were unable to correct a mistake I could spot, how could I trust them to correct those I didn’t notice?

Leave a Reply

Your email address will not be published. Required fields are marked *