Psychotherapy's Six Biggest Mistakes

The list below lays out six of psychotherapy’s biggest mistakes. These are not its only mistakes, but I think they are among the most common, consequential, and correctable.

1. Overlooking the Obvious

Therapists tend to overlook two kinds of explanations for clients’ problems: situational ones and simple ones.

• Example of the first: A therapist attributes a client’s low mood to a depressive disposition rather than to the stress of having just begun graduate school. This tendency to overattribute an outcome to the person while underestimating the situation is known as the fundamental attribution error.

• Example of the second: In Outlive: The Science and Art of Longevity, Peter Attia describes how, with the help of mental health experts, he began conceptualizing his anger as the result of childhood trauma—specifically, as “helplessness masquerading as frustration.” A simpler explanation is time pressure: he sounds like he has too much to do and too little time to do it. Preferring a more complex explanation when a simpler one will do violates Occam’s razor.

• Better practice: Begin with situational and simple explanations. Move toward more personal and complex ones only when they add explanatory value.

• Further reading: What do therapists do with problems they can’t solve?; Mental Illness Is Not in Your Head by Marco Ramos; Why I Do Not Attend Case Conferences by Paul Meehl.

2. Mistaking Diagnosis for Explanation

Psychiatric diagnoses can be useful ways of describing recurring patterns of thought, feeling, and behavior. But therapists often mistake naming a pattern for explaining it.

• Example: Why does he avoid social situations? Because he has social anxiety disorder. How do we know he has social anxiety disorder? Because he avoids social situations. Nothing has been explained. In The Hidden Agenda of the Political Mind, Rob and Jason Weeden call this DERP Syndrome: Direct Explanation Renaming Psychology.1

• Better practice: Treat a diagnosis as a description of what is happening. Then ask what caused it and what keeps it going.

• Further reading: How the Psychologist Got Confused

3. Mistaking Adaptive Responses for Pathology

Therapists often assume that because a response is painful, disruptive, or socially disfavored, something has gone wrong. Shame is painful, hypervigilance is disruptive, and jealousy is socially disfavored, but each can still serve an adaptive function.2

• Example: A therapist treats a client’s jealousy as evidence of insecurity or possessiveness without considering that jealousy can serve an adaptive function: detecting and responding to threats to an important relationship.

• Better practice: Before intervening, determine whether the client’s response is adaptive, miscalibrated, or genuinely malfunctioning. Each calls for a different response.

• Further reading: Good Reasons for Bad Feelings by Randolph Nesse; Toward an Evolutionary Taxonomy of Treatable Conditions by Cosmides and Tooby; The User Manual of Mental Disorders

4. Taking Clients Too Literally

Psychotherapy is conducted through conversation, and case studies and supervision often reduce that conversation to a literal exchange: the therapist said this, the client said that, and then the therapist said something else. But people use words not only to convey information, but also to do things—to thank, appease, test, resist, reassure, or ask for care. By focusing only on what clients say, therapists can miss what clients mean.

• Example: A client says that a tool the therapist provided made a big difference. The therapist accepts this as a literal report of efficacy, overlooking the possibility that the client may be expressing gratitude for the therapist’s care and attention. Instead of simply accepting the thanks, the therapist replies, “If you liked that one, you’ll love this one.”

• Better practice: Consider both the statement (“That tool helped”) and the potential signal (“Thank you for caring enough to provide it”).

• Further reading: Listening with the Third Ear by Theodor Reik; Finding the Right Feeling by Paul Geltner.

5. Overestimating the Power of Insight

Therapists often assume that once clients understand why they feel or behave as they do, change will follow. Unfortunately, knowing the source of a problem is not the same as solving it. A client may understand exactly why they avoid conflict, choose unavailable partners, or drink too much—and continue doing it anyway. Insight can help, but change usually requires something more: practice, exposure, support, altered incentives, changed circumstances, or some combination of these.

• Example: A client discovers that he is holding himself back at work because he fears that as soon as he earns enough money, his wife will want to have children. The insight explains his behavior, but it does not resolve the problem his behavior has been helping him avoid.

• Better practice: Treat insight as one step toward improvement: a guide to intervention, not usually the intervention itself.

• Further reading: Why Insight in Psychotherapy Does Not Always Lead to Behaviour Change by Dariusz Kuncewicz, Kinga Lachowicz-Tabaczek, and Jacek Załuski; and Association Between Insight and Outcome of Psychotherapy by Simone Jennissen and colleagues.

6. Overestimating the Benefits and Underestimating the Harms of Intervention

Because clients tend to begin therapy during unusually bad periods, some improvement will reflect regression to the mean. Other gains may result from natural recovery, maturation, changed circumstances, support from friends and family, help from other professionals, and changes clients make on their own. Yet therapy ends up getting (or at least taking) much of the credit, while its potential costs and harms—including financial and opportunity costs, dependency, and the effects of suggestion—are largely ignored. The result can be an inflated estimate of psychotherapy’s value.

• Example of overestimating benefits: A client begins therapy in the immediate aftermath of a breakup. Six months later, she feels substantially better, and the improvement is attributed to the therapeutic work—overlooking the passage of time, support from friends, and the simple fact that she is no longer in a bad relationship.

• Example of underestimating harms: A therapist routinely helps a client make difficult decisions. The guidance provides immediate relief, but over time the client becomes less confident in his own judgment and increasingly reluctant to act without consulting the therapist.

• Better practice: Humility.

• Further reading: The Psychotherapy Myth by Bo and Ben Winegard; Psychological Treatments That Cause Harm by Scott Lilienfeld; Returning to Ivan Illich

That’s it! I’d be grateful for any additions or pushback.