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.)
