Psychotherapy: can a therapist be right about progress and the client not see it?

January 8, 2012 8:03 AM

Psychotherapy: can a therapist be right about progress and the client not see it? We often hear from people who are in psychotherapy and are in disagreement with their psychotherapist about whether they are making progress. When is the psychotherapist right?

We often hear from people who are in psychotherapy and are in disagreement with their psychotherapist about whether they are making progress. When is the psychotherapist right?

The psychotherapist claims to see progress. The client claims to see no progress.

The most obvious are scenarios are:
The usual answer on Ask MetaFilter is that the client is right and the psychotherapist is wrong, but is this always the case?

Assuming that the therapist is not an out-and-out charlatan who knows the client isn't making progress, here are my questions:

What things or categories of things could a psychotherapist be seeing -- or imaging they see -- that are real and worthwhile but invisible to the client?

If it's ever the case that the psychotherapist's perception of progress is more accurate than the client's does the client ever come round to seeing the psychotherapist's point of view?

I would particularly like to hear from people who are psychotherapists and have had that experience or from people who have been in psychotherapy and retrospectively saw progress where at the time they could not see it.

There's lots and lots of discussion about psychotherapists being ineffective but I'd be interested to hear explanations or discussions of whether or how they can be obscurely effective -- effective without it being apparent to the client.

posted by y6t5r4e3w2q1 to Health & Fitness (32 answers total)

The therapist is an objective viewer. The client is not.

Think of your question this way: lots of people other than an alcoholic see the alcoholic as an alcoholic long before the alcoholic sees himself as an alcoholic. It is much easier for someone other than the person suffering to see the nature of the suffering and how that person has changed, if at all, over time.
posted by dfriedman at 8:04 AM on January 8, 2012

Response by poster: (Please ignore the line "The most obvious are scenarios are:". I thought I previewed the question , but missed that line, that shouldn't be there.)
posted by y6t5r4e3w2q1 at 8:04 AM on January 8, 2012

I'm not sure there's going to be a consistent answer to this question, as sometimes the psychotherapist may be right and sometimes they may be wrong. What I do know is that a client is always entitled to ask for evidence of progress. The client may not think they feel any better, but they can certainly ask "What makes you say I am progressing?"
posted by Miko at 8:13 AM on January 8, 2012 [3 favorites]

Response by poster: dfriedman: Could you give specific examples of changes that could be visible to the psychotherapist but not to the client?
posted by y6t5r4e3w2q1 at 8:15 AM on January 8, 2012

Response by poster: Miko: I'm particularly interested in examining cases where the psychotherapist is right and the client can't see it.
posted by y6t5r4e3w2q1 at 8:16 AM on January 8, 2012

We often hear from people who are in psychotherapy and are in disagreement with their psychotherapist about whether they are making progress.

I don't think this is a common complaint on Metafilter at all. Could you give examples?
posted by Wordwoman at 8:43 AM on January 8, 2012 [2 favorites]

I can't speak much to other types of issues, but at least with depression it is very easy for people to not see progress or dismiss the progress they've made due to the depression. For example, if someone goes to therapy and complains of having no friends because they can't talk to people, and then later in the year makes a friend, they may still feel just as depressed and socially awkward. If the therapist then points out that they have made a friend, which in earlier sessions they purported to be something impossible, the patient may dismiss it as being a fluke, or say the person doesn't even like them that much or they don't even like the person that much, or they're not "really friends" or not the kind of friend they want, or they only have one friend and that doesn't really count, or they still feel lonely all the time, or or or...

Depression makes it very easy to feel like nothing has changed even when much has.
posted by Nattie at 8:47 AM on January 8, 2012 [10 favorites]

Response by poster: Nattie: In this example, isn't it the case that the psychotherapist is using the wrong metric to measure progress? Surely the important thing to be addressing and measuring here would be the depression and sense of loneliness, not the friendship statistic? As you point out, if the client leaves therapy just as depressed as when they went in, they are not going to recognize progress, and in this case, surely the client is right. The progress that the therapist has chosen to measure is not the one that, in the end, is of central importance to the client. (Unless, of course, having a friend relieves the depression, which, in this example, it didn't.)
posted by y6t5r4e3w2q1 at 9:15 AM on January 8, 2012 [2 favorites]

I'm not sure there is a single fact, piece of evidence, or other circumstance about oneself that cannot be over-looked, downplayed, or outright ignored.

We live in a world where there's a television show called "I didn't know I was pregnant" and it seems to never run out of material. As a whole, people are not particularly good judges of anything about themselves.

You're essentially asking if there's anything that a client couldn't possibly miss, and the answer to that question is "No."

So, yes, a therapist can be right about progress being made without the client seeing or believing.

That said, between the question itself and the thread-babysitting you're doing, it sounds like you're not asking what you really want to know and are, instead, trying to get the answer to a different question by attempting to logically eliminate the answer you don't like.
posted by toomuchpete at 9:19 AM on January 8, 2012 [14 favorites]

Response by poster: Wordwoman: there are a few example where people get into specific disagreements with their therapist about the progress of their therapy:

http://ask.metafilter.com/202593/Was-I-right-to-walk-out-of-psychotherapy

and there are others where the client is expressing dissatisfaction with the therapist. I'm assuming that in these examples the therapist must be seeing progress, otherwise, surely they would be ending it (pre-emptively continuing to assume that the therapist's intentions are genuine):

http://ask.metafilter.com/74250/How-can-I-successfully-complete-psychotherapy

http://ask.metafilter.com/65869/does-therapy-work

http://ask.metafilter.com/115336/I-didnt-realise-being-in-therapy-was-a-skill

http://ask.metafilter.com/140518/Non-responsive-psychiatrist-Am-I-missing-something-or-should-I-look-elsewhere



and in other cases, people aren't complaining, they just don't know:

http://ask.metafilter.com/105675/What-makes-therapy-worth-it

http://ask.metafilter.com/48722/Should-I-stay-in-therapy

http://ask.metafilter.com/115274/Am-I-done-with-therapy
posted by y6t5r4e3w2q1 at 9:31 AM on January 8, 2012 [1 favorite]

I'm assuming that in these examples the therapist must be seeing progress, otherwise, surely they would be ending it

Yeah, I don't think your assumption is correct.
posted by Wordwoman at 9:36 AM on January 8, 2012 [1 favorite]

I'm a therapist in training, and I have been taught to set measurable and concrete goals jointly with my clients from the outset of therapy. That means our progress should be definable and not simply a matter of interpretation on the part of either of us. Our goals may include symptom reduction, or they may also be about problem-solving or coming to terms with life circumstances. If a depressed or anxious client wants symptom relief, I have written instruments to help us measure the symptoms after we try various interventions. We also reevaluate goals whenever we need to. So the idea of measuring progress is built into our entire process. Of course it's not always that simple or straightforward, but that's the framework.

Hope this is helpful.
posted by sister nunchaku of love and mercy at 9:37 AM on January 8, 2012 [3 favorites]

Response by poster: toomuchpete: To clarify, I am not asking whether there are things people don't know about themselves, I'm asking what sorts of specific things a therapist might recognize as progress but a client not recognize. Nattie gave an example, which then leads to the question of what progress has value and what doesn't. If the client of Nattie's example is still overwhelmingly depressed and doesn't value the friend, then the fact of having the friend, surely, cannot be claimed as significant progress. Or is it the case that there is something unstated here. e.g. that the therapist believes that when the client has amassed a specific number friends, of any quality, the depression will go away, and hence gaining one friend counts toward the therapists expectation relief of depression, even though it hasn't actually had any effect yet?
posted by y6t5r4e3w2q1 at 9:42 AM on January 8, 2012

When is the psychotherapist right?

Why does it matter?
posted by space_cookie at 9:54 AM on January 8, 2012

When people are depressed, and begin to feel better, they may begin to get back some energy. This can lead to having the energy to carry out suicide, because they may still feel really bad. I no longer have a cite for this. So, I can imagine circumstances where a person might not see the progress that a therapist sees. But if the person asks the therapist for information, and the therapist can't or won't explain, then it seems broken to me.
posted by theora55 at 10:17 AM on January 8, 2012

Response by poster: space_cookie:
Why does it matter?

Not sure I understand your question, can you clarify? Do you mean, why do I want to know? Or do you mean why would it matter what the therapist thinks? Or something else?
posted by y6t5r4e3w2q1 at 10:27 AM on January 8, 2012

OP, the reason why we pay therapists so much is that they're required to make countless judgment calls based on the specific circumstances of a diverse spectrum of clients and needs. I wish it was as easy as quoting from a manual or flow-chart to show how x evidence equals y progress, but just as in your response to Nattie's answer there is no limit to the amount of hair-splitting you can perform, based on factors that are ultimately specific between a certain therapist and a certain client.

This sounds like an issue to discuss with a therapist -- your therapist, or the one of whoever this question's about.
posted by hermitosis at 10:28 AM on January 8, 2012 [1 favorite]

I don't know if this is the kind of thing you are looking for, but here is an example from "The Narcissistic Family (p72), with a bit of background for clarity:

The authors discuss some of the specific traits which arise from growing up in what they term a narcissistic family (elaborate definition, won't go into it). Some of these are lack of assertiveness, bad reaction to criticism, people-pleasing etc. All of these rely on the well-practiced and ingrained denial of emotions to the point where the person coming to therapy no longer feels, recognises and/or validates their own emotions - hence no way to express them, hence lack of assertiveness, people-pleasing behaviour etc. In such cases, the therapist tries to first work on the recognition of emotions (apparently, in the early stages of therapy, people from a narcissistic family background can THINK of very few base-emotions such as happiness and sadness, even when they are only asked to supply a list of emotions with no self-referential pressures). After learning to recognise, acknowledge and validate their feelings, work progresses to expression of feeling etc.

In one of the case studies presented in the book, the person in therapy comes to recognise her physical reactions to a particular event (pain and tension in the neck) and rightly associates it with a negative emotion (anger).

Here the authors go on to say:

"At this point, the therapist was able to praise Mary for the work she was doing, and to underscore the steps that she was taking to change her life for the better. Patients often have a difficult time in recognizing their successes and will frequently acknowledge them in terms that actually reflect deficit or failure ("Yeah, maybe I did it this time, but I should have been doing it all along!"). It is important that the therapist reframe the experience as a deficit of training rather than of inteligence or moral fibre ... the patient did not have the skills .... then [as a child], but she is learning them now".

Based on examples such as the above, I would assume that the situation you describe is relatively frequent, given that therapist and client have a very different view on what is involved to get the desired outcome. Someone mentioned depression above - I remember when I was depressed I was only interested in one thing, and that fast - to not be depressed any more. I would not have, on my own, recognised the small steps in that direction, such as making and having one friend rather than none. But having a therapist (or some other person) show me that this is one step in the right direction would have given me that tiny bit of self-confidence and motivation to give the next step a go and so on until some sort of critical mass is achieved from which I myself can conclude that I am on the right track.
posted by miorita at 10:32 AM on January 8, 2012 [4 favorites]

Why is this question important to you? Why obscure your role and interests here? I assume you have some stake in this question and aren't just abstractly interested in the differing viewpoints between therapist and client.

It will be hard for folks to give you a satisfying answer without understanding more clearly what it is you're after. The scenarios you ask for could apply to a multitude of problems that folks go to therapy to address. Your question is too broadly defined to give you the specifics you seem to want.

An yes, why does it matter what the therapist thinks?
posted by space_cookie at 11:08 AM on January 8, 2012 [3 favorites]

Gaining one friend IS progress, whether a patient remains depressed or not. Being able to say to oneself, when one is depressed, "I have made a friend and my life is a little better for it," is another challenge altogether and can be at times so difficult as to be impossible, and is its own marker of progress, of no greater or lesser value than the acquisition of the friend itself.

If you were broke, depressed, and starving, and you found $100 on the ground that would clearly be a good and useful thing even though it wouldn't singlehandedly alter your prognosis in the short or long term.
posted by TheRedArmy at 11:16 AM on January 8, 2012

Response by poster: If you were broke, depressed, and starving, and you found $100 on the ground that would clearly be a good and useful thing even though it wouldn't singlehandedly alter your prognosis in the short or long term.

Also, it wouldn't be so much progress as chance, which could also account for the one unsatisfactory friend.
posted by y6t5r4e3w2q1 at 11:25 AM on January 8, 2012

To clarify, I am not asking whether there are things people don't know about themselves, I'm asking what sorts of specific things a therapist might recognize as progress but a client not recognize.

The answer is literally anything -- and I mean "literally" literally. Anything a therapist might recognize as progress is something a client might not recognize.

I also suspect that the question "what might a therapist recognize as 'progress'?" has an effectively infinite number of correct answers that vary dramatically based on the client and specific circumstances.
posted by toomuchpete at 11:47 AM on January 8, 2012 [1 favorite]

Your assertion that making one friend (for example; couldn't it be anything that a non-depressed person would be able to do?) wouldn't count as progress if the patient is still depressed is like saying that putting up one wall of a house doesn't count as progress toward having a house because you can't start living in it yet, or like the month of exercise you've put in doesn't count as progress because you're doing it to lose weight and all you've done so far is gain muscle. Some kinds of progress are part of an incomplete but necessary structure; not necessarily enough to get you feeling better on their own, but necessary to keeping you that way once all the pieces are in place. (Provided, of course, that your problem is not so chemical that it is immune to psychological overhauls and external support systems.) As with exercise, there can even be kinds of progress that feel worse at first -- uncomfortable realizations, awareness of cognitive dissonance, a newfound ability to access emotions that may feel terrible -- but are necessary to pass through in order to become capable of doing you want to do.

Claiming that if your suffering hasn't been reduced yet, you're not any closer to feeling better than you were the day you started therapy is some serious all-or-nothing thinking. And a classic hallmark of depression.

As for the "chance" issue: maybe. We'd have to hear how the client made friends with this person and why the client didn't seem to be able to make friends before. Maybe the client would have been befriended even if s/he hadn't been in therapy, but it generally takes a fairly aggressive person to befriend a person whose depressive behaviors -- presumably withdrawal, downcast mood, pessimism, hopelessness, lack of energy, maybe anger, perhaps an intense fear of rejection -- have kept him/her from intimate social contact for a very long time. A certain amount of emotional availability is required, after all. A certain openness. Also, does calling the friend "unsatisfactory" indicate that you think there is some kind of friend who would be able to make the client measurably happier in one stroke? Like the therapist should?

Of course, this is all general talk; we don't know how the patient you're thinking of feels or what his or her therapist has been seeing. The therapist should be able to make some kind of case, although of course a depressed person is going to have extra trouble hearing it objectively through the old hope-stripping filter.

This is one reason people often suggest medication in concert with talk therapy: sometimes you need a kind of painkiller to get yourself into a place where you can even make sense of the idea of practicing and learning and arriving at ways to get better, as opposed to being so constantly aware of your own suffering that anything that isn't alleviating it is a bad joke.
posted by Adventurer at 11:51 AM on January 8, 2012 [7 favorites]

As a therapist whose population encompasses clients who struggle deeply with trust, I can share some measures of progress that I am aware of that the client may not be. First, if the client begins to trust me and share feelings with me, I see that as progress. If the client begins to integrate therapeutic concepts and healthier beliefs, I see that as progress. If the client makes small behavioral changes in the realm of self care (even slight), I would see that as progress. These are small first steps in therapy that a client may not deem as "progress" since client goals are often larger, more broad, more all encompassing etc.
posted by rglass at 12:06 PM on January 8, 2012 [5 favorites]

Progress has to be made incrementally. That's why it IS progress to make one friend, or to make small lifestyle changes that better position someone to make the larger changes that a person with extremely negative thinking patterns might be looking for in order to judge anything as progress. But the big changes don't happen in isolation; they happen through a series of other, smaller changes.
posted by so_gracefully at 12:46 PM on January 8, 2012 [1 favorite]

This:
Adventurer: "...there can even be kinds of progress that feel worse at first -- uncomfortable realizations, awareness of cognitive dissonance, a newfound ability to access emotions that may feel terrible -- but are necessary to pass through in order to become capable of doing you want to do."


Therapy is usually aimed at change.

Change may nog always feel good, especially not at first if you are nog used to doing things differently. Even if you learn to do things which are in the long run to your own benefit, you might do or feel things that seem strange, scary or just wrong.

Other people react to your different approach of things. Even loved ones don't always like it if you change. There may be friction or worse. It is not uncommon for people to end relations during or after therapy for example.

This does nog always look nor feel like things are getting better.
If you're in the middle of that and you are nog as yet assured these things are good, then it may seem there's no progress.

There's also resistance to change. You may do things in a better way that can feel boring or too much trouble, or doesn't give you the thrill you're used to (or addicted to). You'll want to hang on to the comfort of the old ways, these may be not so good for you, but it might feel 'better'.

Getting better is nog always the same as feeling better (yet).

However, if you have a good therapist these things will be discussed.

And then there's all sorts of things a therapist may recognize before the client does, because, well, it's their job, they've done it before and they are (hopefully) good at noticing things.
posted by oenzemain at 1:27 PM on January 8, 2012 [2 favorites]

Therapists should, and most do, focus on functionality, not bliss.

Healthy functional people have stressful lives -- and when they're lucky enough to have all Maslovian requirements satisfied without difficulty, they go out and voluntarily undertake stress for fun, patriotism, what have you. They regularly take actions which risk unhappiness and disappointment. They have insight which causes them to recognize their own, and others', failures and inadequacies.
posted by MattD at 1:42 PM on January 8, 2012 [3 favorites]

The therapist isn't exactly an objective observer. Some people don't benefit from the "expert stance" of that "therapist as objective observer" position.

It can be helpful to have a therapist point out progress that the client doesn't see, but the therapist has nothing to gain by insisting that the progress was made if the client doesn't believe it. (Nothing to gain on the client's behalf. The therapist may gain by seeing progress if mom or dad are paying, or gain self-esteem/feel more competent --see what I mean by 'not objective'?)

On the other hand, sometimes it can be therapeutic to suggest progress has been made even if it hasn't -- if it boosts the client's confidence.

Most important, really, is whether or not a client feels that he or she is making progress, over time. (But what if the client says yes because he doesn't want to hurt the therapist's feelings?)

The idea that the important things in therapy are objective and measurable is borrowed from the hard sciences. That paradigm doesn't hold up well when speaking of human relationships and meaning-making.
posted by vitabellosi at 3:53 AM on January 9, 2012

I am not currently practicing, but when I had a private practice one of the most common signs of progress that I would see in my clients that they would not define as progress was self-realization of problematic thinking/processing. The client would begin to be able to see how they were getting from some experience in the external world to some negative feeling internally. Seeing this connection would not solve the problem for the client, so the client did not necessarily see it as progress, but, from my perspective as a therapist, the client's understanding of this causal chain allowed therapy to move forward to a new level.
posted by hworth at 6:40 AM on January 9, 2012 [1 favorite]

Response by poster: the client's understanding of this causal chain allowed therapy to move forward to a new level

So what happened next?
posted by y6t5r4e3w2q1 at 10:23 AM on January 9, 2012

Response by poster: I mean, what form did the new level of therapy take, and did the client recognize that as progress?
posted by y6t5r4e3w2q1 at 10:26 AM on January 9, 2012

Yes, often a client was able a a later date break thus causal chain and make different choices about his response behaviors. But, typically, this was much later in the therapeutic process. So, while the client would see that as progress, he would not necessarily relate that behavior change to the insight he had had months before.
posted by hworth at 6:10 PM on January 9, 2012