Give Me that Feedback

• Therapeutic Impasse
• Challenging Tribal Suspicions
• Eureka!

Therapeutic Impasse

Rachel is a delightful patient: ambitious, creative, open about her problems and willing to work hard to overcome them. Diagnosed with bipolar II disorder, she had been seeing me in my private psychiatry practice periodically over the past four years, trying one medication, then another: the usual bipolar II fare and beyond (bupropion, citalopram, lamotrigine, aripiprazole, lithium, thyroid, selegiline patch, light therapy, omega 3’s, vit D, hormones). Some months she would be doing well, full of ideas for her business or excited about a new relationship, but these spells didn’t last. She could be depressed for months on end, mired in ruthless self-criticism, avoiding friends, neglecting her projects, spending days in bed wondering how long it would take someone to discover her dead body. With so little success in her pharmacologic treatment, she had lost interest in trying new medications, and, well, frankly, so had I.

Rachel had a therapist, a good one, someone I liked and with whom I collaborated well. We would exchange head-shaking messages, feeling rueful and helpless about our inability to help Rachel achieve her abundant potential. Money was tight for Rachel and her business was flagging due to her discouragement. She was in state of desperation, struggling with intense suicidal thoughts in the face of a depressive episode that had been dragging on for nearly a year. We had to do something! I still felt anemic about the idea of more medications: a stimulant? Did she need ECT? TMS? Ketamine?

She sat in my office, her head in her hands. “How is your therapy going?” I asked her after an uncomfortable silence.

 She exploded in frustration, “She’s not helping, and I can’t talk to her about it!”

“Really?” I responded, surprised, “What happens when you try to bring this up with her?”

“She just gets defensive and tells me it’s my fault, that I’m not trying hard enough!”

Huh. I did not experience her therapist as a defensive person; this must be a depressive distortion, I told myself. But if I bring that up now, Rachel is going to feel even more criticized.

A phone conversation with Rachel’s therapist did little to break the impasse. For financial reasons, Rachel was only able to afford therapy once or twice a month (even with a reduced fee), and I heard her therapist, in the midst of what must have been therapeutic despair, echo what Rachel had told me: “Rachel just can’t seem to muster the motivation to change. I really don’t think I’m able to help her, at least not until something shifts on her end.”

Challenging Tribal Suspicions

As it happens, I saw Rachel right after I’d done an intensive workshop with David Burns, learning about CBT for depression. I’d been trained psychodynamically and had harbored tribal suspicions of this other form of therapy, but my curiosity had gotten the best of me, and I was excited to try the new techniques I’d learned. What if I offered Rachel a brief course of CBT?

Inviting a patient who already has a therapist to see me for therapy, even briefly, is a dicey business. I could easily be helping the patient avoid some important issue that she really needs to sort out with her primary therapist. But when I mentioned this idea to Rachel’s therapist, she burst out, “By all means!” almost laughing with relief. With this blessing, I invited Rachel to come see me for time-limited weekly sessions.

The David Burns brand of CBT therapy, “TEAM therapy,” requires the patient, after every session to fill out an “evaluation of therapy” feedback form, in which the patient scores the therapist for “therapeutic empathy” (How warm, supportive, trustworthy, respectful is the therapist? Does she do a good job of listening to me? Does she understand how I feel inside?), “helpfulness of the session” (was I [the patient] able to express my feelings, did I talk about the problems bothering me, were the techniques useful?). What did I like least about the session? What did I like best?

I’d heard about this idea of getting written feedback from patients, and frankly I’d had a lot of resistance to asking my patients to fill out these forms. It seems like everyone wants your feedback these days (my breast imaging center, really?), and I generally treat these requests with irritable skepticism, believing that my negative feedback will be discounted and that my positive feedback be touted for some political end.

The conference with David Burns changed my mind about that. David Burns is a lot of what you might expect the founder of a therapy brand to be - charismatic, smart, self-confident bordering on cocky. At one point, a young woman (who was clearly still in training) questioned him challengingly. His response was brief and brutal- “I just don’t think you get the point of what I’m trying to say. Maybe you can pass the mic to someone else.” Dinner with a colleague at the end of the first day found us rolling our eyes, snickering at Burns and his narcissistic tendencies. I did not pull my punches on the required feedback form.

The second day of the workshop started with Burns reading aloud the feedback from the previous day. He started with the positive, and unabashedly read effusive comments, “I learned so much! Best conference I’ve ever attended! Love your sense of humor!” His glee at these strokes was charming, and not undeserved - he is an effective presenter and he has a rich set of ideas. Where things got interesting; however, was during his response to the negative feedback, which he read out loud as unflinchingly as he had the positive. “Dr. Burns seems kind of arrogant.” Burns looked up at us with a little grin. “You know, it’s not the first time I’ve been told that. I hope it doesn’t get in the way of your understanding the points I’m trying to make.” And then he read what I had written on my feedback form: “You were incredibly tactless to the young woman who was questioning you.” He sobered and took a pause. “Yes.” Another pause. “I was thinking about that last night. I think I was impatient and became rude, probably even harsh.” He put his hand over his eyes and peered into the audience. “Are you still here?” The young woman tentatively raised her hand. “I am so glad you came back,” he said to her, “I owe you an apology. I am very sorry that I cut you off like that. Are you free during the lunch break? I would like to see if I can do a better job addressing your question.”

As Burns spoke, I could feel my eyebrows soften as my snarky skepticism leached away. Narcissistic guru or no, Burns had been genuinely interested in my critical feedback. He had neither launched a counter-attack nor collapsed in self-criticism; rather, he accepted the truth of the criticism with humility and curiosity. I felt both respected and humbled; the interaction became a meeting of equals, a moment of connection between two people with different but equally legitimate perspectives. When I described the feedback component of the TEAM method to Rachel, explaining that it would be very important for her to tell me when I got off-track, Rachel got tears in her eyes. “I’ve never felt comfortable giving negative feedback directly,” she said. “The only way I can do it is if I know that I am 100% right.”

That makes sense. Perfection is an excellent defense, because what better way to deflect critical feedback than to focus on whatever part of that feedback is wrong? Of course, Rachel would be wary of criticizing me; she could be setting herself up for a counter-attack.

I should note that psychodynamic therapists also work to elicit feedback from patients - they call this “working in the transference” or the “here and now relationship”; it can lead to profound change. The trouble is that many, if not most, patients find it scary to directly criticize someone to whom they are already intensely vulnerable. Since this kind of communication is challenging, it tends to come out impulsively, when feelings are already running very high. More often than not, the therapist, unprepared or already activated, gets defensive and can’t see the important truth in what the patient is saying. Contrast this with asking for written feedback after every session, making it a normal and expected routine of the relationship: the therapist doesn't expect to get it right every time, or even to necessarily know in real time that things have gone wrong. The patient spends a few minutes in the waiting room, while the experience is still fresh, but apart from the direct gaze of the therapist. And likewise, while the therapist gets this feedback promptly, she can digest it away from the heat of the moment, giving her a much better shot at relaxing her own perfectionism and focusing on what is true about any criticism.

Eureka!

So, it was with no small excitement that I awaited my first feedback form from Rachel. I thought our first session had gone okay. We’d focused on her frustration that she wasn’t following through with a new idea about marketing her business. Rachel’s thoughts were brutal: “I’m a failure. Nothing ever changes. I will never accomplish anything.” Rachel’s defense of perfectionism had become a paralyzing shell. For my part, I was anxious that I wasn’t following the steps of the technique in an organized way, and that I might have left out something important. Her first feedback reflected this - she indicated that she felt overwhelmed and that there had been too much bouncing around. In the space to write what she liked least, she said she felt kind of dumb because she had a hard time understanding me, and that I was talking fast.

Talking fast. Ouch! It wasn’t so hard to forgive myself for being new at this technique, but I was grateful to have some time to digest that last bit of feedback. Since I was a child I’ve been told, “slow down, you talk too fast!” I can remember feeling humiliated after chattering with excitement to my grandparents about a story from camp, only to have my grandmother say irritatedly, “Dearie, can’t you just slow down? I can’t understand a word of what you are saying!” It took some work to remind myself that Rachel had usually been able to understand what I was saying, and that there were circumstances that might have made me speak particularly quickly that session.

So, with a deep breath, I pulled out the feedback form the following week.

“Rachel, I see that last week, you felt overwhelmed, and that it was hard to understand the techniques we were talking about. It is a lot to cover, and I think I was kind of nervous doing this for the first time. When I’m nervous, I know I can talk even faster than I usually do!”

Rachel smiled weakly, “You know, hearing you say that is such a relief. I’ve been feeling so stupid all week because I can't keep up with you.”

Ah, one of those therapy paradoxes. I was worried about coming off as incompetent, so I crammed in too much and talked too fast, but Rachel took her difficulty following what I was saying as further proof that she is stupid.

“Hold on, are you saying that you interpreted the fact that you had a hard time understanding me as meaning that you were stupid?” We both laughed.

“Well, now that you say it that way, maybe that one is on you.”

“Yeah, I think so.”

“So maybe neither of us is stupid! And maybe I need to keep telling you when you talk too fast.”

In that moment, I felt like doing an end zone dance.

Perhaps helped along by watching me accept my imperfections, it clicked for Rachel that her recovery would involve her being more gentle and encouraging with herself. She would have to lower her standards and stop demanding that she be in a place she was not. Her feedback that next session was positive. “Heather made it okay to make mistakes.” She embraced the psychotherapy homework with enthusiasm, and by our seventh session, she was feeling motivated and optimistic. On our last visit, we used the relapse prevention technique of making a recording of herself neutralizing every one of her negative beliefs. She wrote on her final feedback form, “We knocked it out of the park!”

It would be hubris to say that the seven sessions we had together cured Rachel, though our work did illuminate her intense perfectionism, and gave her tools for softening it. When I followed up with her a year later, she reported that she was doing well after continuing to work hard in an extensive self-care practice that included 12-step work and an Ayurvedic approach to diet and lifestyle. She wrote: “From our work, I realized that I don't have to be perfect to be happy.” Turns out I don’t have to be perfect to be an effective therapist. I just need to get (and accept) feedback.  

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