Why does a particular treatment approach work with some patients but not with others?
When I was in grad school, they used to say that in therapy, about a third of people get better, a third stay the same, and a third get worse.
And from what I can tell, while we’ve improved some, we still aren’t helping as many people as we’d hope.
But why is that?
For just a moment, let’s imagine that this circle represents all of the people who are suffering:
We help a large percentage of the people we see.
Our treatments and approaches work with those people, and we’ve done a good job helping them heal.
The problem is, even the best modalities don’t work for everyone. There are always clients for whom they just don’t seem to land.
How can we help them begin to experience the kind of relief, healing, and vitality as the other people in the circle?
By synthesizing approaches from the fields of trauma, brain science, and mindfulness, we’ve accomplished so much for so many patients over the last five years.
But I believe we may be on the cusp of discovering the next generation of ideas that could open up greater opportunities for healing to more people.
And I don’t want us to miss this pivotal moment.
You see, lately I’ve been thinking that there’s something about the way we structure our conversations about treatment that could be standing in the way of getting to that next level of ideas.
The leading experts are asked only about their one area of specialty. Often, the same questions are asked interview after interview, conference after conference.
At times, we can almost predict what is going to be said.
If we’re going to make real progress, if we’re going to find ways to help the people for whom our modalities and techniques haven’t yet landed, then we’ve got to think differently.
And that begins with asking different questions.
Because if we do what we’ve always done, we’re going to get the results that we’ve always gotten.
But if we change the way we talk about helping people change, we just might spark the next generation of ideas.
I’ll have more to say about this soon, but now I’d like to hear from you.
Where have you seen tried-and-true treatment strategies fall short? How do you think we can improve outcomes for more of our patients? Please tell us about it in the comments below.
Why don’t more of you accept Medicare?
I think understanding the science of the brain is the key to improved outcomes.
Love that you are asking such an important question Ruth. My work as a social worker largely involved counselling and family therapy, and during that time, I experienced this from both sides of the fence and did some psychoanalytic psychotherapeutic training. Some years ago I became involved in a more holistic therapy stemming from the recognition that trauma is held in the cells – and was a method of accessing and gradually releasing these memories. From the outset I was hugely impressed with the results I observed in others (e.g. as a social worker I had a pretty good idea how long, if ever, it took most people to move on after abuse etc – yet was seeing some of my peers, with whom I was being accredited, genuinely leaving any abuse behind. Gradually I began to realise that it was the body that held the key to this. (Makes sense – if the cells are initially affected – then surely the key is there cp talking about something which occurred many years ago. Many times by breathing into the tension into the body and softening it, the memories arise as they were at the time t/w the emotion etc. Some measure of forgiveness is also an essential part of this. Recently I started receiving some gentle touch by a chiropractor, (NSA) and have been astounded to discover how much more easily I can now access emotions from the past – so this focus on bodywork increasingly seems to me to be the key that is missing in many types of therapy – t/w of course, establishing a trusting, empathic relationship with any client.
I’m devoted to the practice of EMDR for past trauma.
The technique fails me with clients who are unable to visualize (using this in the broad sensory sense of the word for all senses), due, it had later been determined to what would be categorized as a Learning Disorder, though I call it learning difference.
By focusing on the importance of safety and connection; by recognizing so much suffering arises from trauma and loss and by not being afraid to be ourselves in therapy with another. Trusting that our moment to moment interventions come from a deep place of knowledge and wisdom based on training and experience and that therapy is best done in the context of a conversation.
I am not a therapist, but I am raising children/now young adults, am delighted to do community work with children, and love kitchen table conversations- in addition to raising myself! In my experience, the missing piece is community, family, true connection, purpose, acceptance in the flock, in some cases a sober social group. Our social structures are missing this. At my age now, many of us are encountering the empty nest. This is not a mental illness or personal lack of adaptation, or at least that is only a piece of our problem; I feel it is normal for us to need each other and the group in a happy, frequent connected way. thanks for the conversation!
Having been in therapy, known most of my friends during their therapies, i can attest to the value of a therapist that uses several different modalities. As an equine facilitated learning instructor, i have seen people gain deep emotional insights and healing through this work. Using Karla McClarens emotion message chart, learning boundaries in a visceral ways with the horse and interacting within the energy heart field of the horse, the learning outcomes are palpable. I also use Heart Math breathing and coherence as part of the skill building exercises along with Mindfulness and compassion practices from Brach and Kornfield. This lays a wonderful somatic beginning. (some people with boundary issues find it difficult to sit in a small office and talk so being outside is a wonderful release) when people ask for or need more skills, i refer them to a qualified therapist. sometime we work together with a client. The magic happens between the horse as teacher and the client. my horse in particular is gracious with trauma, having been a PMU mare. the conversations between horse and human is a gift i observe from across the fence. i am only the facilitator.
I love all of this, thank you!
Not sure if this is the appropriate place to ask, but I’ll give it a try. I have lived with a person with BPD and I reached out for help for both of us. I never got it. As it is a disease of denial how can you ever get them to counselling or get education of what you are dealing with to the people in their lives? So many people live in silent misery because of this disorder and what it does to families. We just had a national mental health awareness day last week. Now what? Also, if you are an adult, under the law, you have the right to destroy yourself with drugs and mental disorders and your loved ones cannot intervene.
Hi Ruth,
As a therapist of 34 years, specializing in the treatment of people suffering with acute stress and anxiety, I have also pondered the conundrum of how to successfully treat more of the people more of the time. I use mainly a CBT approach, including EMDR, Voice Dialogue, MBSR and MBCBT. Homework is a big component of my treatment and some people are reluctant to do it. I understand that. I have found many creative ways to continue to help clients and am open to new ideas and keep abreast of current trends. Out of frustration, I wrote the following article for my blog and you might find some answers within it:
chrisgfroerer.wordpress.com/2015/05/11/what-is-recovery/
Cheers. Chris
My favorite saying: Everything works for someone, nothing works for everyone, and nothing works forever. That’s why I am an eclectic fan and a believer in common factors. It’s all about the quality of the therapeutic relationship and then believing in whatever tools, approaches, strategies, techniques you utilize, and being able to sell them to the client.
I’d like to hear from Mario Martinez, author of The Mind Body Code…..I believe we will be making breakthroughs in mental health ONLY in collaboration with the medical side of healing research, not just the brain research, which is invaluable, and it’s a step toward a unified approach.
I have had to learn to work hard to hear and feel what the people who see me are feeling and experiencing. Most of my work is done using Skype or face time because of the great distance they are from me. Thank goodness for these “new” inventions. I explain to most of the people I see that they will experience the need for self help. My words are not magic, even though I work hard to establish a warm relationship, they have to be willing to do the home work. I am finding that those who do, get better.
I love your programs, please keep them coming.
Hi Ruth,
I receive Mark’s and your e-mails which I read carefully and appreciate. As I have stated to both of you before that my destiny took me from natural products to synthetic for curing cancer, teaching the pre-med students lab course, through energy to matter and all kind of devices with the vision to leading the best of best team to delivery, design an automated integrated systemic approach for the first time in human history that has created trillions and trillions of dollars economy. This is my claim and I consider it to be God’s grace.
To answer the questions that you have raised. I can state with the highest level of confidence that when the system/systems are constrained, one need to dare and have the courage to thinking out of the box, to understanding and creating a real comprehensible system/systems approach. Instead of publishing books and making more and more money that has no end. I have such an automated integrated approach again to creating real healthy economy that serves the humankind and the God’s interest fairly and justly. Is there anyone ready to helping me this time around? I promise that I will deliver it ethically, honestly, and professionally. Anyone ready to help this time around. please respond. Thanks
Respectfully,
Onkar, 650-965-7939
Maybe do the mindfulness therapy with your clients. It seems we can all use mindfulness and can learn about ourselves through each other. Mindfulness can be a complimentary service.
I agree – a complimentary service. Also practicing nature appreciation on a larger, mindful scale may reach deeper than we think.
Thank you
Social Workers all learn the art of ‘Reframing’ a position in order to shift a client. But, like all professionals with a Praxis approach there are still loopholes; the first is at field placement where the ‘reframe’ is practised; the second is at supervision where the reframe is reviewed for its (inevitable) shortcomings; the third is the most delicate phase – internalizing the reframe principle so it becomes ‘automatic’ in the best sense of that term.
Ruth, I love the concept you’re chasing. Good luck with teasing out that subtle process further. My earliest experience with this was 40 years ago with a psychologist, then a social worker, then a very competent psychiatrist with an interest in psycho-therapy for mental health clients.
All three were (excuse the terrible pun) ruthless in pursuing what was blocking the progress of clients.
Sounds scary but it was mind blowing to watch! And they captured at least a little of the bell curve edges where this group of clients exist.
Social Workers all learn the art of ‘Reframing’ a position in order to shift a client. But, like all professionals with a Praxis approach there are still loopholes; the first is at field placement where the ‘reframe’ is practised; the second is at supervision where the reframe is reviewed for its (inevitable) shortcomings; the third is the most delicate phase – internalizing the reframe principle so it becomes ‘automatic’ in the best sense of that term.
Ruth, I love the concept you’re chasing. Good luck with teasing out that subtle process further. My earliest experience with this was 40 years ago with a psychologist, then a social worker, then a very competent psychiatrist with an interest in psycho-therapy for mental health clients.
All three were (excuse the terrible pun) ruthless in pursuing what was blocking the progress of clients.
Sounds scary but it was mind blowing to watch!
keep doing what you are doing, Ruth … bringing people who practice different approaches or aspects of treatment together. There is hardly ever a silver bullet and that can be true in medicine as well as mental health.
My training and interest have included Rogerian, Freudian, Tolman, Skinnerian, Developmental, Physiologiclal, Neursolinguistic, Eriksoniain, Addiction, Cognitive, Guided Imagery, Attachment and Mindfulness, so I called my practice eclectic. Even so, there were, of course, adolescent and adult clients who did not make progress and/or who left therapy after one or two sessions. As I look back I think I missed the diagnosis of PTSD and of drug abuse in several instances. I think I failed to work through the role of shame in two of my severely depressed clients. I believe I failed to connect at an emotional level with most of the clients who left therapy after one or two sessions. That connection seemed to me to be the sine qua non of therapeutic progress.
We are asking different questions using radically different approaches. Sometimes there is a need for integration that then opens for the next leap of understanding.
I’ve found that teaching and expanding awareness of physical manifestations of emotions brings the best mileage. I have been influenced strongly by “Metaphors in Mind,” by Lawley and Tompkins, who explore and extend the fascinating work of David Grove in healing traumatic memory. They have a method of developing a metaphor out of the physical body sensations, using ultra-clean questioning. Once to that point, EFT, breathing, and other methods, assist the release of the negative aspects.
Hi Ruth,
I do agree that the advances in brain science, mindfullness, and other healing therapies have come a long way and are making a real difference in the social fabric of the world affecting both clients and practitioners.
One change I’d like to see is from the feminist psychology model – where a clients social situation is considered in the mix and supported advocasy is introduced more widely.
For example – how can a rape victim up against an unjust-justice system feel good about herself in the world and feel good about this world?
Only if her real and honest perceptions are fully allowed and accepted and if she were able to find hope and strength with likeminded advocates who work together to make the changes needed to our cultures and society only then do I believe we will see true healing of the real wounds and woundedness that affects all of us.
Thank you for offering this forum to contribute to the conversation.
Namaste
So true and relevant even vital point.
If you cannot feel and “read” your client’s state
Your just guessing in the dark.
This for me involves a vibrational awareness
Which becomes for me a felt sense.
Out of this will come a unique strategy.
I was working with someone who was,overwhelmed
By a zillion thoughts and who was going exterior.
(out of body) . She could not speak. Frontal lobes off line.
I asked if she would like a grounding touch.
She wasn’t expecting this question, nor was I.
I had never asked that question before.
But she responded with a yes, and I safe ported her
By telling her I was going to plave my hand on top of hers.
Would that be ok? She said yes.
As soon as I touched her her breathing slowed down
Her consciousness went back into her body, and
she was able to talk about her feelings.
She said that was the most perfect thing I could have done.
How did you know? She said.
She felt deeply understood and safe.
So no modality, only being totally present and in alignment
mind, body, spirit with the soul in front of me.
Pat Ogden, Van der Kolk, are right about the body
needing to be addressed.
And I had to listen to what my body was
telling me about her state.
Knowing that, I knew what would land.
Learning what IMPLICIT means, during the time our brains were forming, during pre and perinatal times has been pivotal for me– to see the reality of my perceptions–where they came from.
Was there a mammalian skin to skin identification of mother with safety, welcome here?
Was there breastfeeding and carrying close for the first year to glean how to relate to others?
Was there reciprocal relating and respect between all caregivers and contacts?
Mother- Dad Infant
Mother Dad
Hospital personnel Mother/Baby Dyad
OR NOT?
I have gone full circle through all types of therapeutic modalities only to discover that my perception today comes from what went in during IMPLICIT times, my brain being like a SPONGE and MIRROR apparatus. My models of how life is (relating is in our society) and how I am (or rather, how I perceive myself)…..THAT all happened during IMPLICIT times.
So transitioning from what was INCULCATED, to who I am now, is perhaps the final trick.
Speaking casually to veterans during presentations at Veterans’ Court, I discussed the issues of complex trauma and the multiple triggers that stem from multiple traumas. I listened as a frightening set of trauma-related events poured from this veteran. Right time, right place, and/or right atmosphere led to a nice catharsis.
When and how do we sustain long-term access to therapy to effect positive change and post traumatic growth? Can we utilize both paid and unpaid services that would enhance the therapeutic relationships while still paying the bills?
It is complicated.
I’ve just recently gotten engaged in therapy, in combination to other personal inner work I’ve been doing, including a breathwork modality. What I would have to say for myself is that the therapy supports the integration of what I get from my other work, especially the breathwork. Were it not for this other work, which tends to be non-verbal and non-directed, I don’t know that I’d be all that impressed with therapy by itself. Therapy is the support for my other deep work. For the most part, it supports, it doesn’t drive.
The upshot is that both the breathwork modality and my therapist work on the premise that we each have our own inner healer. Therefore, the work is to support that inner knowing, to bring it out and allowing it to direct our work together, rather than my therapist assuming she knows exactly what I need in each moment or each session. She has the training to bring techniques up when they seem appropriate, to ask good questions and to hold space. She also addresses the whole of me, including somatic experiences. But were it not for this inner work and inner healer perspective, I don’t know how much progress we’d make with just talk.
I’d also have to agree with some of the comments below that there is actually being ready for transformation, being ready to be ready for it, and saying you’re ready but not really being inwardly interested at the deep levels that count. That’s again where the holding space of therapy has helped. Building a safe space where it’s okay to get ready to be ready for real transformation, without forcing me to step over the edge before I’m ready.
I do agree with the trend of thought that favors a wholistic approach as opposed to a reductionist one.The single silver bullet approach seldom works.Lets focus on a set of desireable outcomes and then put in place a group of change practices/habits that uses the mind and body…..and remain mindful to the unfolding…..what’s working….N-j0y…nAz
This is personal, and I’m not a therapist, I’m a nurse. But I’ve been in therapy on and off for 30+ years, and finally made some progress using neurofeedback and TRE (Trauma Release Exercises). I think I’ve actually had the biggest breakthrough with TRE. I read Van der Kolk’s book last year, and it pointed me towards EMDR, but I wasn’t as successful with that as I’d hoped. TRE has made me FEEL different. Lighter, happier, more at peace. I think TRE needs exploring further by the various professions that deal with trauma. I can honestly tell you my brain couldn’t verbalize anything, I actually would “go blank” when trying to think about my childhood, but my body seems to be releasing energy, and this has allowed my emotions to come forward in a way that talking, yoga, EMDR and neuro feedback did not.
I have worked as a psychotherapist for years and came to using more and more a non-verbal approach called Sandplay Therapy. This is an approach founded by Dora Kalff in the 80-s, which is becoming more well known. It allows each and every client working their own way through the psychotherapy process. It relies a lot on what Dr. Jung called “a self-healing potential of the psyche” and the “free and protected space” (Kalff, 1980) of the sandplay room, not so much on the therapist talking.
Olga Lipadatova, PhD, RP
I remember learning in one of my early Psych classes about a study that asked therapists and their clients to identify what they thought were turning points and breakthroughs in the therapeutic process. What surprised me (and the authors) was how often the therapists and clients reports did NOT match up despite improvement in client functioning. From this and my own clinical experience, I have come to believe that the journey takes clients where it takes them, regardless of modality or intervention style. That’s not to say one’s approach isn’t important, only that the relationship itself trumps all.
I have to agree with you. If there is no working alliance, ie, a strong relationship with the client that fosters trust in the process, there can be no change.
As someone in therapy for years wohdiffernet therapists, it was not until I met my most recent one that I’ve worked with now for over 3 years. She has helped me identify and move through childhood traumatic memories, release bad habits that were hurtful to me and encouraged me to trust my own instincts. Someway or another all other therapy has failed me because there was always something that instilled more fear and distrust in me from the therapists behavior towards me. Learning to trust this one has given me a sense of safety of being able to say anything, admit to having done things without feeling she will judge me and that has been the key. Finding someone I could trust that has had healthy boundaries for our relationship and yet, will press in and push me to find my own answers. Always, she turns it back to God, and His love for me. Always, she has brought God into the room to assist in “changing” the memories, always she has refered to higher levels of love as something deserved and attainable NOW. These things have helped amazingly. I still do not have full peace, or lightness of being, but what I do have is more compassion and patience for others, which was missing before and getting in the way of my relationships. So trust between the therapist and myself as a gateway to healing. Oh yes! Absolutely! Now I’m ready for the next level. I hope to find it here
In the last few years, I have come to realize that certain quotes that I have heard at conferences or found by reading have been incredibly helpful in healing.
For example,
“You learn more from your mistakes than you do from your successes.” Dr. Berry Brazelton
“Remember, perfection is the enemy to production.” Dr. Catherine Snow
“Grieving is part of healing.” Dr. Jerome Kagan
“There are many people who have succeeded after being told that they wouldn’t.” Dr. Thomas Cottle
It seems to me that how we view ourselves and our world has a profound impact on how we respond to whatever situation we are in. I would bet that many of us are perfectionists and struggle with accepting our mistakes and moving forward. Excellent, thoughtful, quotes can, for some, be the anchors the tumultuous seas of life.
Agreed. I also call them ‘life memes’
I also wonder about readiness. I also feel that the fear of making a change feels so big. Clients may not trust there capacity to heal and change. To them it really feels impossible.
Check out the work of Dr. Ihaleakala Hew Len at in a state mental hospital for the criminally violent based in Hawaii. Profound.
I believe focusing on what the client can do is best way forward. Every client can do something even if it is only to take a breath at a time. Acknowledging efforts and using imagination to create life enhancement.
I always question what is recovery. I believe in striving for change not perfection.
In considering the people therapists are not reaching, I think the inner dynamics of some of those people simply may not have a readiness to want to address their issues. Without that inner consent, “attempts to reach them” may only instill more resistance. Some may really want to be left alone, possibly to fail.
Interesting point. I can relate. And it is true . My deceased partner was one of these.
Humans are social beings. The healing power of group contagion may offer more opportunity.
What is being healthy in an unhealthy world? What sense does it make to be healed for a world of competition, greed, hurt? Learning to keep one´s love, compassion, dignity, nobiliity nevertheless? It´s a hard work and learning. Sometimes i experience loosing any motivation, somehow resignate and stand up the next day again. It´s hard work. Without Vision and hope Viktor Frankl told there is no help
My addictions were defeated by the strength of Jesus. Recovery is not just stopping an addiction. It’s starting a relationship with the Lord and learning our true purpose is for eternal life with God. I’m 21 years sober. Getting closer to Christ daily. This is the answer…
thanks for all those insights and comments, I really agree, being completely present for the client is at the route of a healing relationship, and the start of a working alliance.
Hello, The focus on “the intervention” or “the type of therapy” is misplaced at best What has helped me to be a far more effective therapist is the outcome literature. I would invite anyone to look into the factors involved in good therapeutic outcomes, and a starting point would be to visit the International Center for Clinical Excellence website.
Enjoy
Being FULLY PRESENT is a good first step. Being ready for a client when he/she arrives and having no one in the waiting area when he/she leaves sends the message that the client is the most important client we have at the time. Also, utilizing a mind-body approach speaks to the entire person, not just the mind. Thanks to Dr. Bessel van der Kolk, we know that trauma and negative emotions live in the body, and when we can help the client release these, it can create a shape-change in the mind that had originally fueled these emotions.
Where can I find more information to share with our therapist about releasing the trauma and negative emotions so they can create shape-change WITH KIDS under 12?
The best thing is to be open first of all and make really time and space for that other person, who is like a new planet. first you have to listen and find out who lives on that planet? Can i relate to what I see and feel there? Any method for treatment must come in much much later- first a connection has to be there, a mutual understanding- and then in may experience its more intuitive that things come up which are the right things for that moment for that person. If I am awake and mindful then it will show for me where is the path to go.
Patrizia
Having a multi-dimensional approach such as that with trauma where the emotional,cognitive and bodily approach are all adopted offers a more wholist approach and allows for different “learning styles”, that is that one of those may resonate more than the others at any given time and the thread of which ever it is can be followed by client and therapist. Being narrowed into a singular emotional approach was probably the most frustrating and damaging experience that i had that discounted what i had happenning for me and delayed seeking further treatment for another 5 years…5 years of unnecessary pain because someone thought they knew more about me than me.
I do agree with you Ruth! People get treated with the expertise of the coach/psychologist they go to, and not according to what they really need. Nobody asks “What does THIS person need to get better?” Often the innate resources of the client are also not part of the equation. A whole new approach is necessary.
We need to acknowledge ourselves as mental, emotional, vibrational and spiritual beings, not just physical in order to truly heal.
I believe working on ourselves, together, alone, & at all times, will enhance saying “the right words”… Even when unspoken.
Hi Couldn’t agree more
And that’s why I am going to design a page/blog/site with friends from Alternative Medicine and others to create 10 Minutes each day for people to look forward to . At the moment Im asking everyone interested in Better Health and a Happier life to contribute, so we can integrate all-
Contact Living Well at annegretpsychotherapy@btopenworld.com please!! Glad to send you more info
A small step…
best annegret
Hi Ruth,
Just a few words that mean everything to me :
“Love is All.The rest means Nothing”. “Treasure what has True Worth”.
Kindest Regards,
Peter
Peter ~ So beautiful – so true!
Thank you!
Inula
I believe combining ‘therapy’ with natural medicine such as acupuncture, Chinese herbal medicine, and Reiki can be very effective.
I like the sound of hearing about asking new questions to get different answers.
Thanks