As with any relationship, patient and therapist unions aren’t immune to misunderstandings. When conflict appears, addressing it early on can help patients determine if the therapist and the therapy are right for them.
We often think of psychotherapists as “all-knowing,” which can make patients feel that complaining about the therapy or the therapist is not allowed.
But numerous studies have found that providing feedback pays off. According to psychology researchers, patient feedback can bolster the “therapeutic alliance.”
Similar to relationship chemistry, a sturdy alliance between patients and their therapists includes openness, trust, and collaboration, and according to the American Psychological Association, it’s essential to meeting treatment goals. Regardless of the type of therapy one receives, it’s this connection — the bedrock from which hope springs — that matters most of all.
In their 2015 book, “Premature Termination in Psychotherapy: Strategies for Engaging Clients and Improving Outcomes,” the psychologists Joshua K. Swift and Roger Greenberg point out that unrealistic expectations about treatment, compatibility issues with the therapist and fear of facing painful experiences can cause patients to stop therapy prematurely.
Indeed, studies suggest that 20 percent of patients getting mental health care will end therapy too soon — often without telling their therapists why.
For patients wondering how to give their therapists feedback, here are some suggestions.
Be Direct About Your Concerns
From talking too much or not enough to mislabeling feelings and offering unsolicited advice, therapists may unintentionally upset their patients in various ways. When this happens, broaching the topic by saying, “I’d like to discuss how I feel about coming to therapy,” or “Your recommendations aren’t helpful — here’s why,” are two ways to begin the conversation.
It’s often challenging for patients to be upfront about their therapy concerns when bringing up sensitive topics, research by the psychologists Matt Blanchard and Barry A. Farber suggests.
In one 2016 study, they found that 72.6 percent of psychotherapy patients had lied about their therapy experience. Common lies included pretending to agree with the therapist’s suggestions, pretending to find treatment helpful and masking their opinion of the therapist.
In therapy, these white lies can rupture treatment because it means the patient’s needs aren’t being met. This is why it’s crucial for patients to discuss any negative or unsettling feelings that ensue during therapy.
Perhaps the therapist came across as judgmental, started the session late or didn’t provide a structured treatment plan. Whatever the therapist’s mistake, patients can be direct by stating why they are upset.
When giving feedback, it’s common to pad critical comments with compliments. Organizational psychologists warn these positive statements, known as a “feedback sandwich,” can drown out negative messages.
The same pattern can play out in therapy. Before sharing their misgivings, patients may feel the need to say something positive, as a way to protect the therapist’s feelings. But while therapists are trained to look out for their client’s well-being, patients don’t need to do the same.
If a patient feels hurt by the therapist’s words, it’s O.K. to say, “I’m hurt by what you said, and I’d like to discuss it with you.” If the therapist is sharing too much personal information, patients can set a boundary by saying, “I prefer not to hear your personal stories because I’m here to work on myself.”
Analyze the Therapist’s Response
The therapist should be receptive to feedback. Positive and empathic responses may include apologizing for the misunderstanding, suggesting ways to improve therapy, as well as exploring what it’s like for the patient to speak up and commending their courage for doing so.
But not all therapists respond to feedback professionally. Some may label the patient’s behavior as “resistant,” or incorrectly link the patient’s complaints to unresolved psychological issues. In addition, therapists who become defensive, angry or judgmental when receiving patient feedback may do more harm than good. In these instances, patients may be better off finding a different therapist.
Collaborate Toward a Solution
Once grievances are aired, the stage is set to work toward a possible solution, which may be informed by the type of treatment.
Therapists viewing the therapeutic relationship as a focal point of treatment, known as client-centered, psychodynamic or attachment-oriented therapy, see feedback as an opportunity to strengthen the patient-therapist alliance.
To do this, they acknowledge the patient’s disappointment, anger and frustration. Curious to learn how therapy went off course, these therapists also invite their patients to share more. Because a person’s emotional reaction may offer clues about the nature of their suffering, client-centered therapists might also probe whether the patient’s negative feelings have roots in childhood experiences or traumas. To ease future treatment anxiety, these therapists often say, “If I do or say anything that makes you uncomfortable, I want you to let me know.”
On the other hand, behavioral therapists may meet patient feedback by introducing mental health questionnaires, as a way to collect data about treatment progress. They may also ask their patients to complete behavioral exercises outside of therapy. Doing so allows the therapist to see if the patient’s symptoms are improving and to make adjustments, as needed.
While solutions vary, patients should feel that their needs have been met, and that continuing treatment is worthwhile.
After establishing an open collaboration where feedback is welcome, checking in about the agreed-upon solution or the new treatment plan can help keep therapy on track. Saying, “I’d like to revisit my progress in a couple of weeks,” or “Can I let you know if I feel misunderstood in the future?” are useful questions and reminders.
Unlike fixing a broken bone, healing a patient’s emotional pain isn’t always straightforward, which means patients may feel ambivalent about treatment (even after giving feedback) or become anxious when sharing vulnerable details about childhood abuse, grief, severe depression or intimacy issues.
While numerous psychological interventions can teach patients how to alter their behaviors and face their fears, according to the researcher and psychologist Dr. Allan Schore, ultimately, it’s the emotional communication between patient and therapist that’s curative.
What feedback offers is an opportunity for realness and deeper intimacy with one’s therapist. When this happens, patients can feel seen and heard, which can be a turning point in treatment, as well as in life.
Juli Fraga is a psychologist in San Francisco. Hilary Jacobs Hendel is a psychoanalyst in New York.