How to Fail as a Therapist

books:


	• How to Fail As a Therapist: 50 Ways to Lose or Damage Your Patients (Practical Therapist) Bernard Schwartz, John V. Flowers Impact Publishers, 2006 - 160 pages average customer review:based on 5 reviews view larger image
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highly recommended

A must-read!

It is with great enthusiasm that I recommend How to Fail as a Therapist. Rarely, indeed, does a small book contain such large volume of relevant clinical information. It spans orientations and levels of training/experience on the therapist's side, and diagnoses/ exposure to therapy on the side of clients. As noted by the authors, as well as reviewers on the back cover, this manual is intended for therapists-in-training and for seasoned therapists alike. In this reviewer's opinion, this little book should receive a must-read place in graduate programs for clinical professionals at all levels.

The chapter divisions and titles of specific therapist errors make this manual especially valuable to use as a reference book when self-examination points to omissions/commissions in one's clinical work. Like all good teachers, Schwartz and Flowers have not only articulated a wide range of clinical pitfalls (supported by meticulous research), but also offer ideas (as integral part of the book) and tools (in the appendixes) towards their avoidance or remedy.

Proactive avoidance of many of these errors is the self-evident best use of this manual, and the authors give ample assistance with relevant examples and assessment tools. However, even more valuable to this reader is the comfort that if therapy feels "stuck",
this book can be used as a quick reference for how to "unstick" the therapy process (providing, of course, that it is not too late!). Beyond such future usefulness, reading How to Fail catapulted this clinician to do a first sorting of her own therapy behaviors into a personal list of: (1) "Ooops, I vaguely remember that one but am not doing it"; (2) "Ouch, I am not paying adequate attention to that one; and (3) "glad that I am OK doing this one (more often than not)" etc. Over and above such listing in progress (with the promise to self to make changes!), this clinician revised her intake form to include questions regarding prior therapy (when, how long, issues and outcome) and treatment expectations.

Lastly, echoing the focus by the authors on human resilience, it is reasonable to hope that even with the commission of the occasional therapy error we not only forgive ourselves these professional shortcomings, but that most of our clients do also (and stay in therapy to benefit from their hard work, in spite of our imperfections.)

Monika Davignon, Ph.D., MFT

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How to Fail as a Therapist

This book was very helpful to provide personal examples of mistakes therapists encounter in order to minimize risk in ethics in today's litigatious society. However, it could have offered more comprehensive and critical reasoning and logic behind a couple of the 50 offered examples.

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Very good

This book deals concisely with what it says on the cover and, makes specific recommendations based on the mistakes it identifies.

SUMMARY
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The 50 mistakes are as follows

1 Failing to recognise our limitations as therapists
2 Failing to address client expectations about therapy
3 Failing to inspect the client's previous experience with psychotherapy
4 Failing to explain the therapist's expectations regarding the therapeutic process
5 Failing to prepare clients for the variety of emotions that therapy can evoke
6 Failing to enhance client expectations of success
7 Failing to understand how our assumptions affect (sic) therapeutic practices
8 Ignoring the client's "state-of-change" or commitment level
9 Failing to assess psychological reactance (the patient's receptiveness/resistance to the therapist's formulations)
10 Underutilising clinical assessment instruments
11 Failing to challenge client "self-diagnosis"
12 Failing to assess for the possibility of organic medical conditions
13 Ignoring patient resources
14 Disregarding the data
15 Attending to the messenger and not the message
16 Achieving theoretical rigor mortis
17 Setting goals unilaterally
18 Failing to Develop Collaborative Goals in Early Sessions
19 Failing to include the client in setting session agendas
20 Emphasising technique over relationship building
21 Failing to communicate sufficient empathy and other signs of support
22 Believing that empathy and unconditional positive regard means liking your patient
23 Failing to elicit feedback on the alliance
24 Ignoring the patient's verbal and nonverbal feedback
25 Responding defensively to negative patient feedback
26 Overidentifying with the patient
27 Allowing inappropriate levels of physical intimacy
28 Having boundaries that are too rigid
29 Making inappropriate levels of therapist self-disclosure
30 Failing to set boundaries for out-of-session client therapist contact
31 Developing the "Out of session activity" unilaterally
32 Failing to adequately prepare clients for the assignment
33 Failing to provide backup support to increase compliance
34 Failing to prepare the patient for attitude change
35 Relying on passive learning strategies
36 Failing to attend to the client's core beliefs
37 Failing to explain that attitudes are not fixed beliefs
38 Responding passively to the client's unproductive behaviours
39 Responding in an aggressive or insensitive way
40 Failing to prepare clients in advance for the possibility of medication
41 Failing to be prepared for client objections, concerns and resistance to medication
42 Failing to discuss termination early in therapy
43 Failing to follow proper termination procedures
44 Confusing termination with abandonment
45 Failing to be prepared to deal with the myth of time limited therapy
46 Failure to monitor one's own well-being
47 Failure to balance work and leisure
48 Ignore the comfort zone of the environment
49 Overspecialising
50 Undervaluing the power of human resiliency

The ways, that I found helpful, to avoid the mistakes are summarised below.

HISTORY
* Ask about the good/bad bits of the last session (23)
* Ask about good elements of the session (2, 23)
* Ask about bad elements of the session (2, 23)
* Past experiences media and friends who have had therapy (2)
* Past experiences with other therapists: duration, ending, relationship, best bit, worst bit, what should be changed, treatment too fast/slow (3)
* "What do you think is likely to happen as a result of your treatment?" (6)
* Assess change stage: "Who in your life is most concerned about this problem?" "What have you done or thought about doing about this problem." "How long has this problem been a concern?" Use a "readiness ruler" (actually a visual-analogue scale) of the patient's commitment to change
* Methodological search for patient's strengths (13)
* To prioritise treatment goals: what difficulties are the problems causing, what might happen in the future, what goals might someone in your position have, which goal fit/do not fit you? (17)
* To increase personal efficacy: when have you been able to shake off the problem, how have other people you have seen done it, in your fantasies how did you tackle the problem? (17)
* To increase commitment to change: how would life be better/worse, get support from? (17)

MENTAL STATE EXAMINATION
* Assess for reactance: interruptions, arguing, off-task comments, negative responses.
* Note what is not being said (17)
* Note: eye contact, disclosing less, greetings warmth (24)

FORMAL TESTING
* State of change assessment tool McConnaghy et al (in the book) (7)
* The Hong Kong Scale of Psychological Reactance (in the book) (9)
* Use a counselor satisfaction questionnaire (one in the book and other suggestions) (23)

ASSESSMENT
* Discloser/nondiscloser person (5)
* Shutdown/unaware of their feelings (5)
* Distraction used to cope with emotions (5)
* Belief system: people trustworthy/not trustworthy, locus of control, altruism/selfishness, people complex/simple
* Use the HRS instrument to assess homework barriers (33)

MANAGEMENT
* Inform a trusted colleague when you feel you made an error (1)
* Educate about collaboration (2, 17), treatment approach, duration, termination (2, 42), door-knob disclosures (4), painful emotions might be evoked (5), exposure therapy (32)
* Identify obstacle to exposure (32)
* Prioritise session goals (4)
* Set treatment goals (17) early in treatment (18) and early in sessions (19)
* State the goal even if it seems very obvious (19)
* Recognise that for some patients the goal is to develop a goal (19)
* Leave time at the end of sessions to clarify goals (18)
* Do not assume that the obvious goal is the patient's goal (18)
* Accept "baby steps" (6)
* Low directiveness and high collaborative for those with high psychological reactance and vise versa (9)
* Identify times when the patient has been successful, in therapy and life (13)
* Have the patient record how many times they resisted the impulse to drink and not just if they drank or not (for example) (13)
* Enhance your credibility by describing experience with other cases (20)
* Do not be overly formal (20)
* Convey positive regard (20)
* Carl Rogers 3 imperatives: unconditional pr, therapist congruence and empathic understanding (21)
* Act in accordance with the fact that you probably feel you are being more empathic than the patient thinks you are (21)
* Ask oneself: do I need to hear more of what the patient is feeling and do I need to imagine how I would feel in this situation in order to connect? (21)
* Connect with the person behind the repulsive behaviour (22)
* Recognise that from strengths, not weakness, change will come (22)
* Imagine the emotion leading to a different outcome (22)
* Make patient feel safe to voice their concerns (25)
* Admit your fallibility (25)
* Use any rupture in the relationship (25)
* Do not attempt to rescue (ie do more than is appropriate) (26)
* Some self-disclosure but stop a LONG way short of matching the patient (29)
* Brainstorm the hierarchy then the patient orders it (31)
* Enhance compliance with home work with: post it notes, getting someone else to encourage them, do the activity with someone else, frame the assignments as experiments, leave little to chance (33)
* Made assertive communications as needed
* Make firm rules for therapy behaviour especially for couples therapy (39)
* Tell people if their behaviour will not help treatment (39)
* Terminate if: poor progress, patient not willing, patient too hard, conflict of interest (42)
* Do a summary session no matter who decides to terminate therapy of if it is planned (42)
* Do not terminate during a crisis, for your sake alone or quickly (44)
* Note that with the exception of father daughter incest, as a group, those with traumatic events are only slightly worse off than those without the events
* Have a phone call made to patients to confirm the (first) appointment.

PROFESSIONAL DEVELOPMENT
* Compare your termination rate with the norm (1)
* Remember "Perfection is the enemy of the good."
* Do we believe people can change? (7)
* What is our belief system/how do we regard strangers (7)
* Use Wrightsman's Philosophy of Human Nature Scale (in the book) (7)
* Remember that charismatic teacher are not always right (14, 15)
* Humility (1, 16)
* Read stuff (16)
* Get therapy (26)
* Identify the patients who push your buttons (39)
* At professional development meetings, share how you are coping (46)
* Take the Maslach Burnout Inventory (1981)
* Note if you are irritable with patients, have less interest in your profession, procrastinate at work or have scheduling with no breaks
* Don't overspecialise

REVIEW
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Like the person who wrote the book's foreword, I do not agree with everything in the book. For example, they say never to give out your mobile number, they make a scatty troubleshoot of rational emotive therapy (the difference between attitudes and core beliefs in not important, and doing RET well will avoid the pitfalls they mention), and their retelling of the African Violet Queen story is almost certainly inaccurate (I suspect they did this to avid exaggerating the story).

Their treatment of countertransference was a scatty too. They do not use the term "identify" correctly or define it. They state "recognise that working effectively with patients does not mean that you `feel their pain.'" It is not made clear if this statement is an ideal or a likely outcome of treatment. Unfortunately it is the human condition that unless you are profoundly autistic you will find yourself mirroring the patient's emotions - it is silly of them to skirt around this fact.

On page 50, they state "the misconception here is that having positive regard for someone equates to liking the person." Well, technically that true. But the authors ignore the fact that its pretty damn close. I think the authors own boundaries are too rigid. They discuss a junior therapist getting (psychodynamic sounding!) therapy for overidentification or fusion with a patient but steer clear of pointing out that therapists enter into a real, emotional relationship with their patients and that this can be done safely. In most settings, if you don't like someone, you don't have to and/or should not treat them.

The authors also reccomend professional development by reading journals. I recon that books much better; they might be 5 years out of date but at least the information is presented in such a way that you have a hope of keeping up. Likewise the authors reccomend PubMed as a way of keeping up with medications. This is absolutely not a good idea at all. Read a general, introductory book or ask someone about them.

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fun and frightening book

I liked this book, for it poses the ways we can and should be vulnerable. Instead of hiding behind the illusion that we know what we are doing, it shows how and how often we make mistakes as therapists. Let's be honest folk, we fail all the time, and still get paid for our failures. Instead of burying our patients with whom we fail as physicians, we simply say "they weren't ready," they were non-compliant," "they were resistant," or any array of moving the locus of responsibility away from our mismanagement and on to the patient. If we can honestly assess our failures, we'd be better therapists and better as a field. Well done.

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How to Fail as a Therapist

This a great book, for trainee and newly graduated therapist.

Depending on which study you read, between 20 and 57 percent of psychotherapy patients do not return after their initial session. Another thirty-seven to 45 percent only attend therapy twice. A follow-up study on dropouts found that most clinicians had no idea why their patients had terminated, whereas their clients could define very specific "therapeutic errors." Clients who dropout early display poor treatment outcomes, over-utilize mental health services, and demoralize clinicians.

It doesn?t have to be that way. There are a number of well-researched strategies which have been proven to reduce dropout rates and increase positive treatment outcomes. How to Fail as a Therapist is a manual for practicing clinicians and clinicians-in-training, detailing the fifty most common errors therapists make, and how to avoid them. Therapists will learn to avoid such failures as not recognizing one?s limitations, performing incomplete assessments, ignoring science, ruining the client relationship, setting improper boundaries, terminating improperly, therapist burnout, and more.

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