Admitting failure in therapy

In the article 'Talking failure in therapy and beyond' (December 2017) Rousmaniere and Wolpert discuss the limited efficacy of talking therapy and the reluctance of most psychologists and health service providers to acknowledge it. They are right on both counts, but their discussion might imply that this issue has never been openly aired, which would be false.

Thirty-five years ago, the American psychologist Bernard Zilbergeld tackled this challenging subject in his book The Shrinking of America. In the same country, back in the 1980s and 90s, a very large-scale and well-conducted trial called the Fort Bragg Evaluation Study assessed community-based mental health services for children and adolescents – all of which included a large element of psychological treatment – and found them to be no better than routine outpatient clinical care. Likewise, in a series of publications that spans several decades, the academic and researcher William Epstein has demonstrated the systematic and serious scientific shortcomings of the psychotherapy evidence base.

For most of his career, the late David Smail wrote in depth about this topic from the standpoint of a British clinical psychologist. He showed how psychological treatment must fail, when so much individual distress arises from the combination of ineradicable personal history and of a toxic social and political world. The whole discipline of community psychology is built upon a similar understanding.

Finally, there are many current writers in the field – such as the Midlands Psychology Group – who see the doubtful performance of psychotherapy as an unspoken but fundamental issue for all practitioners, and for anyone who wants to understand the roots of unhappiness and what might realistically be done about it.

Paul Moloney
Counselling Psychologist
Royal Shrewsbury Hospital

It was stimulating to read the exchange of emails by Miranda Wolpert and Tony Rousmaniere (December 2017) on the topic of failure in therapy, not least because of the format. A preliminary dialogue reveals more than a finished article. The openness and honesty of the exchange stimulates an equivalence in readers, at least in this reader. I can resonate to Tony's sense of shame at having failed and the huge reluctance to acknowledge this to colleagues.

My doctoral research into social skills training (SST) failed to show that this relatively new behavioural therapy worked as I desperately wanted it to. Instead of examining the reasons for this, I completed the doctorate and put it into the back of my mind. Only later when I collaborated with Keith Winter on single-case studies of SST did I begin to tease out why I had failed and what factors might be important in this essentially educational model of therapy. Based on our research Keith and I wrote a chapter on SST for Foa and Emmelkamp's Failures in Behavior Therapy (1983, Wiley), one of the earliest books on the topic. Sadly, Keith died not long after in a terrible accident in the Atlas Mountains and our collaboration came to an end. I went on to practise as a psychotherapist for 37 years during which time I had my share of failures. It was these more than my successes that led me to publish my memoir, The Gossamer Thread: My Life as a Psychotherapist (2010, Karnac).

Tony rightly points out that in other professions failure is understood and anyone claiming 100 per cent success is likely to arouse suspicion. To his list of reasons why failure has been a taboo subject in the therapy world, I would add that it can be difficult to know what success or failure looks like.

I used to lecture on the Encounter Group movement that sprang up on the west coast of America in the 1970s. Carl Rogers was the most eminent name associated with these new approaches. When quizzed about their effectiveness, Rogers stated that he would hope that people who benefited would become more aware of their problems and enter into therapy, the converse of what most therapists seek to achieve. Rogers was not being provocative. He had a very different idea of mental health from the quasi-medical model that dominated so much of psychotherapy research and, sadly, still does.

Implicit in all forms therapy is a set of values about mental health and mental illness. When someone presents with symptoms of depression, anxiety or PTSD, they are likely to see themselves as ill and seek help to recover. The discourse has been shaped that way by mental health experts, psychologists included, and by the way the NHS works. Therapists often collude in this model, especially when they look to NICE to justify what procedures they can use.

Evidence-based psychotherapy, with which I concur, has been distorted to fit the medical model despite the overwhelming evidence that specific techniques are dwarfed by the therapeutic relationship in terms of outcome. In an American task force review, specific techniques accounted for only 10 per cent of the variance, whereas common factors such as the therapeutic relationship accounted for 30 percent (Norcross & Lambert, 2011). Both may be important, but the skew towards techniques derives from the dominance of the medical model.

For many, depression, anxiety or other psychological state reflects their current condition not an illness. The truth is that anyone's emotional state is a product of the individual and the environment they find themselves in.

A large part of psychotherapy is discovering and exploring these factors. If success is only construed as 'getting better', then when that fails, there is no option but to blame something, the therapy or the inexpert therapist, or indeed the patient who may come to see himself or herself as a persistent failure. In so many cases success is not the transformation of someone from 'ill' to 'well,' but a better understanding of why we feel the way we do combined with support for what changes may be made. Perhaps Carl Rogers was not so far off the mark.

'Fail again. Fail better,' wrote Samuel Beckett. Or as the writer and psychoanalyst Adam Phillips once wrote, 'Tyrannical fantasies of our own perfectibility lurk in even our simplest ideals, Darwin and Freud intimate, so that any ideal can become another excuse for punishment. Lives dominated by impossible ideals, complete honesty, absolute knowledge, perfect happiness, eternal love are experienced as continuous failure.'

John Marzillier
Oxford

Reference
Norcross, J.C. & Lambert, M.J. (2011). Evidence-based therapy relationships. In J.C. Norcross (Ed.) Psychotherapy relationships that work: Evidence-based responsiveness (2nd edn). Baltimore, MD: Johns Hopkins University Press.

Illustration: Tim Sanders