Disclaimer: I am a master's-prepared, licensed therapist with 32 years of experience. I am neither an expert on medications nor a physician of any ilk.

The Boil-Down: Tens of millions of Americans receive therapy every year. Most of it does not work in any robust way. Integrated Trauma Theory predicts that mental health therapy (aka "psychotherapy") is less likely to work the more triangulated it is--and is actually more likely to be harmful. What follows are seven signs that your therapy is occurring on the PVR Triangle.

The Details: If you rely on any search engine, it will pull up a stack of results showing statistics about the effectiveness of therapy; these stats rarely line up, and most of the sources are non-scientific. However, it's still worthwhile to look at the results of face-valid surveys in which real human beings have reported to clinicians or researchers about their therapeutic experiences.

Let's get one thing out of the way: the "treatment" this article discusses is therapy. However, if you check around the world of psychiatry or general medicine, the "treatment" they will reference first is medicine--psychopharmacology. In their QuickStats report, the CDC's primary definition under the term "mental health treatment" is whether people did or did not receive medication for their mental health condition(s), even though sources unabetted with the medication industry (for abetted sources, check out links like the one from medicalxpress; they unethically pitch non-robust survey results as strong support for antidepressants) repeatedly cite little to no help from psychopharma beyond the placebo effect (that's when just knowing you're taking something that's supposed to help makes you feel better--even when it's just a sugar pill). Peter Simon asserts that clinical trials consistently show a two-point difference between an antidepressant's chemical effect and the placebo effect on a depression scale; such a slim difference is considered "clinically imperceptible."

So what do websites peddling specific remedial therapeutic modalities say? They seem to do their best to legitimize the therapy they stand behind; and by the way who wouldn't? I try to do that for the reader when it comes to the therapy I practice. In one example I have chosen not to cite, a specific therapy protocol for a specific mental health diagnosis reportedly results in a 55% reduction in symptoms and a 22% improvement in life satisfaction. Who wouldn't be pleased with that? And as the devil's advocate I ask, Why stop there? What keeps that therapy from yielding better results? If you're a return reader, you may remember my assertion that separate, purist models of therapy tend to be reductionistic; that is, the focus tends to be myopic and the concepts tend to be oversimplified. The necessary broader context--and therefore many possible antidotal points of intervention--tend to be left out. Integrated therapy is generally far better. That is, the more models of therapy your therapist has studied, practiced and innovatively expanded upon, and the better she understands how to weave them together in key moments during your course of treatment, the more you'll benefit. 

And what do therapeutic websites say about behavioral health therapy in general? Multiple searches suggest that anywhere from twenty-five to seventy percent of people who enter therapy feel it does not help in a significant way. It's tough to pull a thread of explanation through all of those surveys and articles when they don't necessarily track variables like therapist experience, client motivation or number of sessions attended.

In previous blog entries, I have referred to a phenomenon known to Eyes Wide Open as the PVR Triangle. This is a way of conceptualizing and diagramming human trauma dynamics when people behave and experience one another in traumatic re-enactments of perpetrators, victims, and (absent/failed) rescuers. As the author of this blog, I have consistently asserted the theoretical prediction that human individual functioning and relational functioning within such triangulation ("on the triangle")will suffer, ultimately devolving into dysfunction. Mental health, whole health, wellness and well-being will consistently struggle on the PVR Triangle, and narcissistic gravity and its destruction will flourish.

The purpose of this article is to help the reader recognize when therapy is triangulated, how it is triangulated, and to what degree--and what to do about it. Just as other relationships suffer under the affliction of PVR triangulation, so will a therapeutic relationship. Ready? Here are seven signs your therapy is triangulated:

1. When you are going to therapy primarily to get confirmation that you're right.  There is nothing wrong with entering therapy which leads to affirmation that you have been traumatized, or that you are a worthy human. That's all good stuff; those are therapeutic steps forward on the journey to recovery. However, if you are basing your sense of okayness on the therapist synchronously agreeing with you on an ineffective stance you're maintaining which is part of the problem--such as a wounded self-story or tactical avoidance--then you are challenging the therapeutic space to enable an unhelpful sense of bias. A therapist with a trained, experienced eye for such triangulation will likely call this out. However, some therapists will unwittingly fall into a position of enablement, which will forfeit much of that therapy's ability to help you improve your life.

2. When you select a therapist hoping they will avoid a painful topic that needs to be addressed for the sake of your health and well-being, and they do avoid it with you. It is not unusual for a person to enter therapy torn or trepidated. They may feel daunted or afraid of having to lean into an issue that feels too overwhelming to address, or face a habit of which they suspect they will need to let go. Also, every therapist will eventually meet a client who presents with a palpable implicit plea silently (or overtly) beseeching the clinician not to confront issues like the client's excessive drinking or their sexual shame, when gently and directly doing so will actually be in the client's best interest. Therapists who ignore the intuitive inner voice speaking to that countertransferent observation (hey, there's an elephant in the room that needs to be named) --or who are too out of touch to detect that voice in the first place--are doing their clients an unfortunate disservice. The situation is triangulated by an unhealthy "rescue."

3. When you select a therapist who seems unsure how to navigate after the first session...or any number of sessions later. When I was a young, wildly inexperienced practicum student, my ethics professor (who also happened to be the program director) playfully joked that I was too inexperienced to do my therapy clients any real harm. I took his insinuation seriously, adding fuel to my motivation to be the most effective therapist I knew. Unfortunately, when I sought therapy for myself, I experienced the same thing so many of my clients reported about their previous counselors: they turned out to be what a colleague of mine calls "one-trick ponies." These non-judgmental, fully licensed empathic listeners, to paraphrase family therapy guru Jay Haley, were "being therapists without knowing practically anything." Their failure to master an integrated model of therapeutic change means your therapist has triangulated you into saving them from doing their job. Their implicit plea to you is, please just pay me and pass the time with me and somehow feel better without my having to lean into my own needs, deficits and fears as a professional.

4. When your attendance seems to be meeting your therapist's personal needs.  Sometimes "wounded healers" are so sick or self-centered that they may attempt to be friends with, live in the same house with, relapse with, or have sex with their clients. If this has happened to you, please get away from them, report them to authorities and give therapy another try with a reputable professional so that you might find recovery support in the wake of such harm. More often, however, the indications that your coming to therapy is meeting your therapist's personal needs tend to be more subtle. You may or may not feel supported and even make progress in such a situation. But if you seem to be counseling your own therapist, if you find vast amounts of the session devoted to his talking about himself in a way that does not immediately apply to your own wellness and recovery, and/or you get the idea that your therapist would excessively miss you or struggle if you terminated, firmly bring it up to him or move on. Your therapy is triangulated.

5. When your therapist teams up with you against the humanity of someone who isn't in the room. In some cases, a therapist's own unresolved transference with certain types of attachment figures (for instance, unresolved issues with father figures) may neglect to gain awareness of how their own internal reactions unhelpfully influence the way they end up taking sides--which is never supposed to happen; therapists are ethically trained and obligated to maintain neutrality. Clinical neutrality is employed specifically to prevent triangulation. But when you describe ineffective experiences with a friend, partner or family member whom your therapist has never met, and she speculates that the absent person being discussed should be diagnosed with borderline personality disorder or is "probably a covert narcissist," etc., or otherwise paints this person as "the problem," then your therapist's lack of neutrality has triangulated the treatment space. "Yep, the girlfriend you're having trouble with (whom I've never met) is almost certainly a 'toxic cheater.' If I were you I would break up with her." Yep, that's triangulation.

It would be interesting to "workshop" the reactions of clinician readers who might reactively rebut that labeling or expressing contempt for absent others (or for that matter, co-clients who are sitting right there in the session) is justified when the opposed "other's" alleged actions, or the favored client's lived experience, seems to be egregious enough. By the way, triangulation is obviously still occurring if your therapist opposes you by defending some absent other person during your session, making your humanity the problem.

6. When your therapist consistently "leans out." If your therapist can't seem to affirm you, won't listen to your feedback and requests, says things to make you feel contradicted, misunderstood or invalidated, or acts like you shouldn't be talking about your symptoms or personal experiences because they can't handle it ("maybe we shouldn't talk in detail about your car accident, it makes me queasy"), it is your prerogative (and you owe it to yourself) to firmly and directly point it out to your therapist. If you don't get an immediate and lasting positive adjustment from your therapist, you need and deserve a different therapist.

7. When your therapist can't seem to join you within your personal moral preferences or unsettling internal experiences. One of the most common errors I have repeatedly heard about and professionally observed in other clinicians is their unwillingness or inability to accept or work from within a client's morality, personal philosophy, paradigm for living, religious/spiritual culture, family culture or ethnic culture. These doctors, nurses, psychologists, counselors, therapists and social workers often act too uncomfortable to be effective, or iatrogenically (that's when a sworn licensed helper does harm) imposes their personal beliefs upon the patient/client and the therapeutic space--which is supposed to be flexible, receptive, and safe. While it's absolutely true that sometimes the client's rules for living are contributing to the complaint and need to be examined and changed, health professionals must NOT attempt to force clients to vote the way they do, observe family folkways the way they do, or see God they way they do. To have any chance of being helpful they must leave plenty of space for such preferences. It is also imperative that clinicians hold space with people who are displaying maladaptive social skills or experiencing psychotic, suicidal, obsessive compulsive, or dissociative symptoms.

What You Can Do: First of all, be willing to perform some research before committing to a specific therapist, or even a given clinic. Diligently look online using sites that are neutral and reputable, not sites pitching their own treatment fraternity without clear ethics in the name of capitalism. (I am biased, but the best one I know is www.psychologytoday.com). Avoid massive corporations or "therapy farms," especially those suggesting that somehow their help is the "best help" or magically outperforms others. By the way, if you select a therapist at a practice run by psychiatrists or other physicians, do not be surprised when they do a lot of diagnostic testing and labeling, then listening in relative silence or light conversation without engaging in any robust deep work or skills-based, neural interventions, instead encouraging you to simply take your meds and be sure to follow up with your pill pusher. While there may be effective physician-run psychotherapy clinics out there, do your homework before choosing.

Show up open-minded. If you start therapy in the hopes of being coddled or enabled, or having your bad habits overlooked or endorsed, you're not even in an effective mindset to engage in serious behavioral health treatment. If one of your primary objectives is get your therapist to support your application for long-term disability benefits for major depression, or to obtain a letter of permission for an emotional support animal, consider that a warning sign that your life is on a trajectory for completely unnecessary long-term unwellness.

Know when you're in a grief stage of "bargaining." Have the self-awareness to understand any tendency you may have to avoid difficult topics or address horrible memories or severe symptoms. Entering therapy hoping you won't have to broach a specific issue is potentially self-defeating, so be sure to bring that up to the therapist right away.

Have the courage to switch and start over. If you happen to initiate therapy with a clinician who seems too inexperienced or personally unwell to be thoroughly helpful to you, openly discuss this with them. Be assertive enough to tell them if you're deciding to switch to another therapist, and why. Knowing that you experienced them as unhelpful, too unskilled, or simply incompatible gives them the chance to receive that information with a growth mindset and make improvements to their craft. While quietly dropping out of bad therapy is less polite and less helpful, it's still better than staying in bad therapy.

Report therapists who are unethically harmful or dangerous. When in doubt about what constitutes unethical behavior, the most reliable guides are professional association codes of ethics held by organizations like the American Psychological Association, the National Association of Social Workers, the American Counseling Association, and the American Association for Marriage and Family Therapy. Knowing a therapist's affiliation makes it possible to review ethical codes on the pertinent association's website. If you personally experience clear ethical violations or worse--hateful, threatening, dangerous or sexualized conduct--get safe, get support, and file a report with either the therapist's association or state licensing board. If another adult tells you they had such an experience, encourage them to file their own report. If you learn about clinician ethical violations against children or other vulnerable citizens, you may be legally obligated to cause a report to be filed depending on the laws and regulations governing the state in which the violation occurred.