What is effective treatment? Would you be able to describe or define it if you had to?
Most people would struggle to define effective treatment because there is no real consensus on what that is. For many clients, “effective treatment” is being able to connect with the therapist, develop a trusting relationship, and heal from challenges faced in life. Sounds easy enough right? Not so much. Effective treatment cannot occur if there are barriers. Barriers could be anything from behaviors, negative thinking patterns, or attitudes of the client to therapist incompetence, attitude, or lack of knowledge.
This article will briefly discuss some of the barriers that often prevent effective treatment from occurring in therapy.
Being a therapist can be extremely difficult. There are so many reasons why this is but one very true reason seems to stick out the most for a large percentage of mental health therapists: effective treatment. Effective treatment is defined as “treatments that are based on scientific evidence…: In other words, it is treatment that has been studied, researched, and tried multiple times with multiple groups of people to determine its effectiveness or therapeutic value. Before Cognitive Behavior Therapy became an evidence based treatment for therapy it had to undergo years of study and “field study” (i.e., tested with real people in real life settings) before it could be labeled “effective.” As you probably already know, CBT is one of the “go to” therapeutic tools for most therapists today.
Sadly, despite the existence of evidence based treatments, not all therapeutic tools (including the so called evidenced based tools) are always effective. Sometimes treatments are ineffective because of common denominators such as client attitudes or behaviors, personality disorders, or therapist attributes, attitudes, or skill level.
When I see clients for the first time I often encourage them to tell me a bit about their previous therapeutic experience. If their previous experience was a negative one, I attempt to show them that therapy can be positive, especially if they are honest, open, and willing to grow.
Sadly, I have seen a few clients who make therapy very difficult on themselves and for the therapist as well. Such clients often engage in the following behaviors:
- Refusal to allow therapy to work: Because of a negative experience in therapy, a desire to do the complete opposite of what they should do, or outright opposition for the sake of being difficult can all result in failed treatment. Individuals diagnosed with borderline personality disorder may display behaviors that seem to interfere with the progression of treatment. I have treated individuals with personality disorders who intentionally disrupt therapy for the purpose of controlling, dominating, or throwing it off course.
- Rejection of medication management: Medication can be tricky and it isn’t for everyone. When I see clients I recommend they try holistic and natural options before trying medication, unless they have a severe mental health or medical health condition that requires it. In most cases involving children and teens, parents are highly concerned about introducing or increasing medication to therapeutic doses that may result in negative side effects, dependency, or severe withdrawal symptoms. So you probably can’t blame people who fall into this category. But some clients intentionally reject medication to be difficult or to protect their right to choose. Other clients are afraid of what might happen if they start or continue medication. When mental health conditions create discomfort or dysfunction in the person’s life, medication is necessary and refusal can prolong treatment or recovery.
- Lack of empathy: Empathy is an important attribute to have because it allows you to put yourself in the shoes of someone else. To feel what they feel. To imagine how they must feel about something. Without empathy, therapy is difficult because therapy is all about discussing challenges, family dynamics, social relationships, emotions, thoughts, feelings, behaviors, etc. etc. etc. Without the ability to empathize with others, growth will be stunted in treatment. For example, how can a father grow in therapy if he cannot understand the embarrassment he causes his 14 year old daughter when he shoes up to her school plays drunk? How could a controlling and emotionally detached husband understand his wife’s feelings if he can’t see how much stress he places on her when he calls her names or attempts to control her freedom? Empathy is important. A lack of empathy is often a sign of a personality disorder and as you know, therapy with these individuals can feel almost impossible.
- Lack of insight: Lack of insight means no ability to grow, adapt, or learn. Insight is important for evaluating decisions, attitudes, perspectives, behaviors, etc. and without it, therapy will suffer. A person who is unable to evaluate themselves or others will often remain confused in therapy. Therapy can begin to feel like an uphill climb to nowhere. Therapy doesn’t truly begin until the individual is able to see how they affect others, how others affect them, and how they react and engage with the world around them. Individuals who lack insight may also refuse very important aspects of treatment such as hospitalization, medication, etc. The individual may also refuse to complete “homework assignments” outside of therapy or follow through with techniques learned in therapy.
- Strong or oppositional personality: Being strong-willed isn’t always a bad trait. I’m sure you would agree. But when a strong-willed person begins to exhibit an oppositional, rebellious, uncaring, and dominating personality, treatment will suffer. I often admire clients who are able to speak up for themselves, weigh the pros and cons of things, engage in back and forth evaluation with a therapist about their lives, or speak up when needed. But I do have challenges with clients who refuse to cooperate, even after seeking treatment for themselves and asking for help. Sometimes this contradictory behavior is a cry for help. But other times, it is simply a game being played for the heck of it. Sadly.
- History of difficulty with healthcare providers: A history of challenges with healthcare providers can be a clear sign of potential challenges in the future with healthcare providers. Do you know someone who has had a difficult journey with healthcare professionals and cannot seem to find someone they connect with or trust? Throughout my career I have met clients with histrionic personality traits or borderline personality traits who struggle with trusting healthcare providers of all kinds and work very hard to avoid or control them. Difficult adolescents such as those in the juvenile delinquent system or those with conduct disorder (i.e., fire setting behaviors, animal cruelty, opposition, disregard for the rights of others or authority, etc) may also struggle with multiple healthcare providers. Can you see why this would be a barrier to treatment? Individuals who struggle will “hop” from one provider to the other until they find “the right one.” While I totally get that this can be healthy and should occur for some people, “hopping” around is sometimes a game or attempt to avoid something.
- Borderline Personality Disorder traits: As I have discussed in previous articles, some individuals with BPD traits often find themselves in limbo when it comes to therapy. On one hand they truly want to get better, while on the other hand they want to avoid responsibility and treatment. An inability to trust, develop healthy bonds or expectations of others, fear of abandonment, etc. can all lead to the individual putting up as many barriers as possible to avoid fully engaging in treatment and trusting the process. Clients may also find themselves creating drama each week to report to the therapist to throw the therapist off course from focusing on the ultimate goal of treatment. BPD traits can slowly corrode the therapeutic relationship.
- Embarrassment, shame, or guilt: These negative emotions can cause clients to avoid therapy altogether. I don’t blame them. When I am dealing with guilt over something the first thing I want to do is hide or avoid. I don’t want to challenge the issue, face it, or talk about it. Many clients feel this say way, especially children and teens who lack the emotional maturity to cope better. When these emotions are difficult to overcome, therapy is often stagnated.
- Substance abuse: Alcohol addiction or drug abuse makes therapy very, very difficult for a variety of reasons. Some reasons include but are not limited to: inability to commit to treatment, lack of focus or concentration, low motivation to change or pursue D&A treatment, internalized shame and guilt, challenges with severe mental illness and substance addiction, etc. Individuals who are struggling with a dual diagnosis (e.g., substance abuse and bipolar disorder), may struggle the most to commit to therapy and accept that they need support.
Do you know someone who may fit the above descriptions?
As always, I look forward to hearing from you.
All the best to you