Stop Treatment-Shaming Your Clients

Imagine that you fall and break your leg, and the hospital staff point out how clumsy you must have been. Or you visit a dietician who greets you with, “Wow, look at how fat you are.” Or you get prescribed a medication that makes you horribly depressed – but your doctor insists that this is evidence-based medicine and sighs that you aren’t treatment compliant.

Few doctors would ever treat their patients this way. But unfortunately – with the best of intentions – some psychotherapists subtly (or even not-so-subtly) shame their clients in the name of treatment. Especially in recent years, as there has been more of a move to treat things like fears, phobias and PTSD with strategies that involve talking reluctant clients into doing hard things like exposure.

Facing your fears head-on, especially when administered compassionately and at the right dose, can be life-changing for many people. Unfortunately, this has also ushered in a culture change where some therapists feel doing a good job means practicing “tough love” and being agents of confrontational change - and in the process, unwittingly employ shame as part of their treatment strategy.

I sometimes joke that cognitive behavioral therapy, the approach I practice, has evolved over time from relaxation and desensitization to something resembling teaching people to bungee jump off a bridge. Joking aside, some therapists have an almost-gleeful focus on pushing people to do exposures nowadays. I respect that, but in some cases this crosses the line into an unhealthy power dynamic where we stop listening to our clients, minimize their limits, and treat anything that goes wrong as their fault.

A tough-love strategy might make sense if treatment always worked for everyone, but unfortunately it doesn't. While ERP (exposure and response prevention) has become a go-to approach for issues such as OCD and anxiety, a recent meta-analysis of RCTs for ERP shows that it is still far from perfect, and I personally know of several people – including clients, fellow clinicians, and even myself – who have been traumatized by over-eager exposure therapy. (For example, this article describes how Atlantic Magazine editor Scott Stossel went through an exposure for vomiting that went horribly sideways - and how he was shamed into it by his CBT therapist, despite his misgivings.)

This same dynamic has been true throughout the history of psychotherapy. From psychoanalysis to mindfulness, our profession sometimes encourages an unspoken ethic where our dogma is Right and our clients are Wrong. Or worse, brands too many of these clients as treatment-resistant and sends them away. In the process, we can lose sight of how horrible it is to suffer from mental illness, struggle with treatment, and conclude that you are beyond hope and it’s all your fault. 

So how can you be a good evidence-based therapist without shaming your clients? Here are my thoughts:

Normalize everything. Every single time. Are they sharing concerns about their treatment? Nod empathetically and say, “of course.” Do they have severe symptoms? Tell them they have lots of company, and it’s treatable. Did they slip up on their therapy homework? I tell them “Nobody does therapy homework perfectly” – and then get to work with them on next steps.

Don’t confront people with their symptoms. Some therapists promote having clients face up to how much their illness is costing them in the name of “treatment motivation.” I see where they are coming from, but I've also personally seen this backfire badly in the wrong hands. There is a thin line between helping people inventory their recovery goals (a good thing) versus "look at how bad off you are" (a really bad thing), and it can plunge people into hopelessness at a time when their self-esteem is already in the toilet. So at the very least I'd be r-e-a-l-l-y careful.

Stop weaponizing terms like “evidence-based treatment.” It implies that you are right, and when it doesn’t work, they are somehow defective. In my experience, the problem is usually that YOU need to go slower, try a different approach, or suggest another expert.

Never use the phrase “treatment compliant.” Your clients aren’t disobedient schoolchildren who aren’t doing their homework, and shouldn’t be treated that way. They are human beings paying you to get well, and your approach isn’t working for them. Always troubleshoot, never criticize.

I personally have a bias that ERP usually works best at a gradual pace where people experience lots of support and success - and that good evidence-based treatment is a smorgasbord with more than one flavor on the menu. But wherever you plant yourself on the treatment spectrum, there is nothing about evidence-based therapy that precludes being kind, collaborative and focused on discovering what works best for each client. 

And never presume you have all the answers: we've made wrong guesses about treatment ever since the days of Freud, and who knows what we'll learn over the next decade - or from our next client.

One of my clinical colleagues put it well: to use an analogy from behavioral experiments, “the rat is always right.” To which I would add that evidence-based therapy – or any kind of therapy – works best when you stop shaming your clients and listen to them.

(Image by Jenny Friedrichs from Pixabay.)

Tofu and OCD Treatment: The Case for Harm Reduction

A few years ago, I went to a homecoming football game at my alma mater Cornell University - and learned first-hand why OCD treatment fails as often as it does.

Before the game, my old department had a tent party with a spread of food: one tray piled high with ribs, another with hamburgers, and a third with "healthy vegetarian sandwiches."

Guess how that turned out? The ribs were gone in short order, the hamburgers soon after. But even though many people were still complaining about being hungry, the kale-and-tofu-sandwich pile sat there completely untouched. (As for me? The ribs were delicious, and I was glad I came early.)

I know what many public health experts would say: that these people were making bad choices. That evidence shows they would be healthier and live longer eating the tofu sandwiches. That we need to invest in more education about better eating habits.

Here's what I would say: if we want people to eat healthier, we need healthy food that more people actually eat.

As a trained OCD therapist who suffers from it personally, I feel exactly the same way about OCD treatment. Exposure and response prevention (ERP) is currently the gold standard for treatment, with a great deal of literature behind it. It basically involves doing what makes you uncomfortable, without doing any of the behaviors you normally do to soothe this discomfort, until you get used to it. And even with newer models like ACT and inhibitory learning, the focus is still on distress tolerance.

The problem is that many people - and for that matter, many clinicians - like exposure therapy about as much as they like tofu. It often (but not always) helps when people DO it, but the same literature will tell you it fails about half the time because of factors such as treatment refusal, dropout, treatment failure and relapse. Some people simply won't do it - and more importantly, some people bravely do it and it simply doesn't work, or kinda sorta works. Too often our treatment community has nothing to say to this unlucky 50%, and promotes a message that recovery is only for the special brave people.

In fact, current clinical research sometimes seems bent on making treatment more uncomfortable with each passing year. For someone like me in my sixties, I've watched the CBT field evolve from Barcaloungers and Valium to a joyless focus on exposure and distress tolerance. As for research on how to make treatment more palatable with fewer dropouts, I mostly hear crickets. People should be eating their evidence-based tofu, and that's that.

I am not a Luddite about ERP. I practiced it and taught it. I've seen it work firsthand. And I deeply respect the lived experience of people who feel it has changed or even saved their lives. So I get their fanaticism for it. But I'm also gently suggesting that some of you may be handing many of your clients nothing but tofu sandwiches, and dismissing many of them as treatment failures.

But in my humble opinion, perhaps we could reach more sufferers - and more clinicians - without throwing the evidence-based baby out with the bathwater. There is an approach that already works in fields like addiction, tobacco cessation, and social services. It's called harm reduction.

Harm reduction is exactly what it sounds like. If you are an alcoholic and can't quit, drink less this month. If you are hooked on cigarettes (only 15% of whom ever quit, according to the literature), vape for now. If your social services client is a hot mess, explore what strengths they can build on to be a little less of a hot mess this week. In short, ease people into long-term success by building short-term confidence, versus making them scale what, for some, is an impossibly high wall.

What might harm reduction look like in OCD treatment? Instead of promoting "torture therapy," think about evidence-based strategies that help but are more palatable – like controlling rumination, very gradual exposure, mastery instead of habituation, or the right kinds of cognitive approaches. Think of an "ERP Lite" that most people won't fail or drop out from, that we promote as the first line of treatment. Which can then, of course, be titrated up to torture therapy for those who truly need it.

This was frankly my own approach when I was in practice, and it actually worked quite well. Instead of asking people to make themselves uncomfortable, I asked them to stay comfortable and gradually expand their comfort zones - and had close to a 90% treatment response rate. But what one obscure therapist in upstate New York thinks doesn’t matter: what matters is what research shows to be effective. And we’ll never know unless more people DO that research.

"But ERP is the only evidence-based approach for OCD!" Umm … sort of. Just this month, a newly-published meta-analysis of RCTs on ERP concluded that successful ERP studies basically correlate with researcher bias. They also concluded that it is better than placebo but not significantly better than other treatment approaches, gains from it are modest, and its research outcomes aren’t duplicated in actual clinical practice.

So first of all, I think my evidence can beat up your evidence. Either way, we still fail far too many people whose suffering matters. And we desperately need to build an evidence base that looks beyond painful treatment approaches that too many people “flunk” and too many non-OCD therapists are reluctant to use. Which means doing better research that puts treatment acceptance front and center.

So would a harm-reduction approach help more people, with fewer dropouts and treatment failures? We won’t know until someone decides to make this a research hypothesis. And we should. Oh and, by the way, I'm allergic to tofu.

(Photo credit: Ponyo Sakana from Pexels)