The Dark Pool of Psychotherapy

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In the November 2018 issue of the Journal of the American Academy of Child & Adolescent Psychiatry, I wrote a critical review of a book by a well-known author about using play therapy for children with post-traumatic stress problems (Scheeringa, 2018a). In the book, the author described a case of a mother who was, in the author’s opinion, overprotective. This mother was unhappy that she was not being told by the therapist what was going on during therapy sessions with her young son. The mother finally confronted the therapist: “This is what I mean, you never say anything specific: What is he saying, what kind of play is he doing, why does he scream in your office?” The author of the book portrayed this mother as unenlightened, demanding, and unreasonable. I interpreted this as the correct concerns of a reasonable parent.

This mother’s experience is not uncommon. I hear often from parents about therapists who are not transparent with them about their children’s psychotherapy. There are two problems with keeping caregivers in the dark about psychotherapy sessions. First, even if therapists are doing a good job, parents cannot know that if they do not know what is going on in the treatment room. What techniques are children learning? What treatment targets are being addressed? What complications are coming up? Second, psychotherapy is, quite simply, a difficult profession. Psychotherapy is complicated and uniquely applied to every patient, and many psychotherapists fail to follow best practices (Shafran et al., 2009).

If parents are not kept informed about what transpires in psychotherapy, there is no one else to monitor the quality of it, and there are good reasons to be concerned about the quality of psychotherapy. To be clear, I’m not saying that parents need to be in the therapy office for any of the actual therapy work with children. I’m saying that parents need to be kept in the loop, just like surgeons report to parents post-op how operations went on their children. As I’ve written about in a previous blog, consumers have more information about the quality of shingles on the roofs of their homes and the breakfast cereal on their kitchen tables than they have about psychiatric care.

Quality of psychotherapy is a legitimate concern. Research on how psychotherapy is actually practiced in the community supports the concerns of parents who are shut out of therapy offices. There is an enormous amount of evidence now that evidence-based treatments (EBTs) are usually more effective than treatment that is usually delivered in community clinics. Weisz and colleagues (2013) conducted a meta-analysis of 52 studies that compared EBTs head-to-head with usual care in youth samples. They found that while there were some instances in which usual care was as effective or better, the superiority of EBTs was widespread and consistent.

Despite the enormous expenditure to train clinicians and disseminate EBTs in the last three decades, few clients in community clinics actually receive EBTs. In a 2009 review of the literature, the authors found that less than half of patients with a variety of disorders received EBTs, and even when an EBT was delivered, it was delivered suboptimally (Shafran et al., 2009). Because many therapists are apparently not using best practices, there needs to be some level of transparency of what goes on behind the closed doors.

When it is unknown or unclear what psychotherapy therapists are delivering, I call this the dark pool of psychotherapy. The dark pool of psychotherapy represents counseling that is conducted without sufficient transparency. For children and adolescents, this includes failure to regularly update caregivers about sessions with child patients. For adult patients, this includes failure to be clear about what treatment techniques are being used. It also includes not following best practices, without any type of standardized monitoring.

Here is another example of the dark pool of psychotherapy. We treated a 6-year-old girl with 49 therapy sessions at my clinic to help her deal with physical abuse from her biological mother and adjust to adoption by her grandparents. The grandparents had to move an hour away from the clinic, so they decided to transfer her treatment to a clinic closer to where they lived for convenience. But this new clinic bothered them. For nearly every session at this clinic, the new therapist came out to the waiting room, took the child alone into her office, and did not routinely involve the grandparents. The grandparents were unhappy about this procedure, but were particularly shocked by it because they were used to our model of including them briefly at the beginning and end of every session to get updates, involve them in parent management, and keep them in the loop about progress. However, they did not tell the new therapist that they were unhappy about being kept in the dark about their child’s treatment because they did not want to rock the boat.

It is not terribly difficult for therapists to be transparent about their treatment techniques, but it has not been a standard of care in most clinics. It is possible for patients and parents to do the monitoring themselves. For example, in the appendix of my book, I provide a checklist of the key elements of cognitive behavioral therapy that patients and families can use to track with therapists (Scheeringa, 2018b). This appendix can be used as a template for any type of psychotherapy treatment plan.

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