Common Mistakes Even Experienced Therapists Make

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Here are six therapeutic blunders that even highly experienced therapists make. While not a complete list of "rookie mistakes," these tend to be the most common.

1. Being too limited by certain boundaries.

Many therapists practice defensively by hiding behind rigid therapeutic boundaries because they fear litigation, Licensing Board regulations, or because their approach is very boundary-based (e.g., psychoanalysis). Thus, many therapists will not answer simple questions ("Where are you going on vacation?"), disclose anything personal about themselves ("I was born in Johannesburg, South Africa"), or even accept a small gift from a client. Of course, any therapeutically helpful boundary transgression must never involve sexual, exploitative, or manipulative conduct. But driving a stranded client home (say, one who doesn't have AAA and whose car won't start), escorting people beyond the consulting room during anxiety management exposure, or merely accepting a small gift is more likely to enhance therapeutic outcomes than hinder them. Also, being open to some degree of gratis communication between sessions can be very helpful for clients. Basically, having the flexibility to see therapeutic boundaries as “signposts” rather than “hitching posts” almost always strengthens rapport and the therapeutic alliance, thus facilitating good results.

Caveat: Obviously, when treating people with significant personality disorders (e.g., borderline, narcissistic, dependent, etc.) or manipulative natures, firm boundaries are essential.

2. Being too limited by their use of preferred methods, even when others have been shown to work better.

In the mental health field, too many therapists have a standard regimen that they use on everyone. Frequently, a form of treatment that might be helpful for someone might be unhelpful or even harmful for another individual. Worse, some therapists have only a single tool in their therapeutic toolbox (e.g., supportive, non-directive therapy; psychoanalysis; mindfulness; assertiveness training; etc.). Obviously, if all one has is a hammer, one will be tempted to treat everything (or everyone) like a nail. A really good therapist, however, will tailor the therapy to suit each client's specific needs, rather than attempting to fit them into his or her preferred method. This, of course, requires that therapists are flexible and adaptable, and have an eclectic therapeutic toolbox containing a variety of techniques, strategies, and procedures—ideally ones that have scientific backing and empirical support.

Caveat: Therapists need to be aware of their skills and limitations. Taking a few CEU credits on CBT, ACT, EMDR, or mindfulness, for example, does not automatically equip someone to add those tools to their toolbox.

3. Using methods with no scientific or empirical support.

Despite not being limited by a one-dimensional therapeutic toolbox, some of the methods that eclectic therapists use have no validity, empirical support, or scientific backing. Thus, even when there is clear-cut scientific evidence that specific procedures work to solve particular problems, or treat certain conditions, many therapists still won’t utilize them and insist on subjecting their clients to dubious techniques instead. And even when techniques are empirically supported and evidence-based, a therapist must know when they are indicated and how to employ them. For example, using hypnosis, trying to achieve “insight,” relaxation training, and/or cognitive restructuring will not be helpful in treating OCD or many other phobias. What the evidence tells us is that exposure-based methods are the treatments of choice. Hence, many therapists with a self-described eclectic approach still choose to ignore the data and rely on methods that “feel right," or make intuitive sense, despite the absence of supporting scientific findings. The result is that the science of psychology and methods of clinical practice often fail to connect and consumers are often not helped or even made to feel worse. The problem here is the placebo response which is a very real phenomenon. But if a method helps only about one third of people with a particular problem (a typical placebo response) and a best practices intervention helps more than two thirds of them, it is a pity if it is not used.

Caveat: Of course, just because a method or technique lacks scientific verification does not mean it should be jettisoned entirely. Despite being increasingly grounded in empiricism and evidence, therapy remains a synthesis of art and science. What’s more, many helpful techniques have not yet been scientifically investigated or are too multifaceted to be amenable to standard research methods.

4. Failing to consider biological disturbances.

Many therapists are not adequately trained to identify common biological disturbances or medical conditions that can masquerade as psychological problems. For instance, thyroid imbalances can present as depression or anxiety, medication reactions can cause mood problems and insomnia, and many other medical illnesses can cause psychological symptoms (e.g., diabetes, anemia, and heart disease, to name only a few). In fact, research suggests that about 80 percent of physical illnesses are missed during initial mental health assessments (Matteson, 2015). Most often this occurs because the clinician has not spent time taking a thorough medical history. The danger here is that many people with emotional, mood, or thought disorders tend to seek out mental health services before they consider a medical assessment. It is not until they get worse or develop an observable physical illness that they seek medical help. Unfortunately, by this time the disease has often progressed to a serious level. Obviously, most therapists are not trained medical doctors. Nevertheless, if there is even a minor suspicion of symptoms being caused by an underlying biological disturbance, referral to to an appropriate medical specialist is imperative. Sometimes, something as simple as failing to determine how much coffee someone drinks, or what supplements they take, can result in therapy that misses the mark.

Caveat: Here, too, therapists must know the limits of their expertise and not pretend to be M.D.s. Insisting that all new clients undergo a thorough medical workup prior to starting therapy, for instance, would be absurd. Rather, the onus is on therapists to acknowledge the importance of biological factors and educate themselves to appropriately weave that knowledge into the therapeutic tapestry.

5. Refusing to recommend medication.

As stated above, most therapists are not trained as medical doctors and mostly think outside of the medical model. While this can often be beneficial, it can sometimes be problematic (as noted above). What’s more, some therapists go so far as to eschew any medical intervention, including the appropriate use of medication. Nevertheless, sometimes the single-most important intervention a therapist can make is convincing a client to try a course of psychotropic medication. For instance, without appropriate medication, most people with bipolar depression, severe major depression, incapacitating OCD, or psychoses will likely fail to be helped no matter how hard they try in purely psychosocial therapy.

Caveat: This necessitates that therapists have a basic understanding of psychotropic medications and feel comfortable collaborating with prescribers. After all, therapists spend much more time with their clients than most other healthcare professionals. Thus, when sufficiently knowledgeable, they can gauge efficacy, tolerability, and compliance very well and meaningfully collaborate with prescribers. At a minimum, knowing when, how, and to whom to refer for a psychopharmacology consult is important.

6. Being too rigid to open the therapy to a marital, relationship, or family processes.

Another common mistake that even highly experienced clinicians make is refusing to expand the therapy to include their client’s significant others. They believe that once an individual therapy process has been established, it must remain individual. Therefore, instead of having a few meetings with a client’s spouse, partner, parents, or family, a rigid practitioner will refer that process to other therapists. Obviously, if a therapist feels they are not qualified to effectively incorporate a few relationship-focused sessions into the individual therapy, they are doing the right thing by referring. But for those who have training and experience with couples, relationship and family therapy, it is a lost opportunity not to open the “individual” process to significant others. I routinely invite a spouse or partner into the proceeding—with my client’s blessings and consent, of course. Indeed, I have sometimes learned more about some of my clients from these collateral sources in a single session than I had in several individual meetings. Similarly, when treating a couple (or a family) having occasional individual sessions can be equally helpful.

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Caveat: Naturally, if a significant conflict of interest is deemed likely to enter into the picture, keeping matters clearly separate and defined is important. Otherwise, having the flexibility to “change gears” is usually in the client’s best interest.

Remember: Think well, Act well, Feel well, Be well!

Copyright 2019 by Clifford N. Lazarus, Ph.D.

This post is for informational purposes only. It is not intended to be a substitute for professional assistance or personal mental health treatment by a qualified clinician. The advertisements contained in this post do not necessarily reflect my opinions nor are they endorsed by me.

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