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3 Things Therapists Shouldn't Say

These responses can be harmful to the therapeutic relationship.

Key points

  • The therapeutic relationship is considered a key to positive outcomes for patients, but three phrases used by some helpers can tarnish it.
  • Saying "I understand" is well-meaning, but can be taken as a patronizing gesture or sign that the provider has had a similar experience.
  • "There's not much we can do about that" may seem like a path to getting patients to accept a circumstance, but can create collateral damage.
Cottonbro/Pexels
Source: Cottonbro/Pexels

“The road to hell is paved with good intentions” is an ancient phrase. One interpretation is that sometimes trying to do something good can have unintended bad consequences.

Unfortunately, this referenced road can detour through psychotherapy offices.

We’ve all created awkward moments of seeming to know precisely how to say the wrong thing, or perhaps the right thing in the most wrong way. Embarrassing blunders tend to have a way of ensuring we don’t make the same mistake twice, but not all insalubrious exchanges generate such obvious signs we need to make a change. Did you ever consider you may be oblivious to regularly making therapy-undermining remarks because they seem like innocuous, relevant, and even supportive statements?

Hidden in plain sight are three utterances that could be standing in the way of forging therapeutic alliances. While well-intended, they can generate feelings of being minimized or misunderstood; patients may believe they are incorrigible and even doubt the practitioner’s ability.

“I understand.”

This reflexive comment always seems like the right thing to say because it shows you’re paying attention and/or empathizing, right? But this is a specious perception. Have you ever noticed that sometimes that phrase has earned you a snappy reaction?

Early on, I worked in acute settings, where people were frequently in crisis. More than once, I thought I was nicely applying my attending skills as the patient or their family explained what disastrous event was occurring. “OK, I understand,” I mindlessly replied. And more than once, I was met with some derivative of, “Do you? Then get me/us out of this!”

My comment was taken as if I had a similar experience and knew how to successfully deal with it. When it was clear I had no silver bullet, the moment was pierced by another dose of irritation aimed my way. I brushed it off that they were in a bad space, and it had little to do with me. Upon reflection, however, they were having the worst time of their life, and it was as if I offered false hope of relief. Why wouldn’t they be more irritated?

On another note, consider that many people entering therapy feel entirely misunderstood by those around them and may not even understand themselves. Is it not premature and perhaps even patronizing in a canned response sort of way for a therapist, someone they just met, to offer, “I understand”?

Luetenberg and Liptak (2012) list saying “I understand how you feel” as one of 15 solid active-empathic listening skills. However, it should be cautioned the professional only says this if they really do. Otherwise, as noted by personality disorder expert Dr. Joseph Shannon (2019), patients, especially those with certain personalities, will likely sense disingenuousness, and it can tarnish the alliance.

These things considered, I urge supervisees to take great care in how “understand” is used. Perhaps the one situation in which “I understand” is safe to say is in prefacing self-disclosure that could strengthen the therapeutic alliance. Otherwise, for use as an attending skill statement, it’s essential that “understand” be qualified with “that” (i.e., “I understand that it’s a painful situation for you.”). Even so, replacing “I understand” with “I recognize…” “I can see that…” or “I hear you” to show you’re following along and being empathic can help avoid any ricochets.

“There’s not much we can do about that.”

A patient who struggled with tinnitus (ringing in the ears) once complained that their neurologist’s reply was, “There’s not much we can do about that.” Indeed, there are no known cures for tinnitus, and many things cannot be reversed, including people’s painful histories that bring them to treatment. This, of course, doesn’t mean the effects can’t be managed.

Such a response to a patient’s struggle may seem like an appropriate way to ground them in reality and make them learn to accept the situation. Ironically, even if the intention is to ground them in reality and bring them to acceptance, is that not “doing something about it”?

Imagine being so desperate for relief that you decide to attend therapy or otherwise seek treatment for an ailment and being on the receiving end of “There’s not much we can do about that.” It implies the very thing you want help with can’t be dealt with, period. Not surprisingly, my patient described increased anxiety. Tinnitus is itself anxiety-provoking (e.g., Kherle et al., 2015; Pattyn, 2016; Abbas et al., 2019), and this was then compounded by hopelessness.

Ironically, the neurologist’s response was inadvertently helpful in this case. Anxiety and stress are believed to exacerbate tinnitus (e.g., Guitton, 2006; Moon et al., 2018). We, therefore, capitalized on this opportunity, and the patient learned they had control over the tinnitus by revisiting the things from earlier in treatment that were most powerful in assuaging anxiety. As the anxiety decreased, the acuity of the tinnitus diminished, and they felt empowered.

Reflecting on my own early experiences and discussions with supervisees, “There’s not much we can do about that” may be more of a case of “I’m not sure how to help you with this.” The fact that someone is deceased, you can’t rewind to the past, or there is no known cure is an easy escape to try and redirect to firmer footing for the therapist.

“You just have to...”

A similar line of thinking is offering, “You just have to suck it up/do it/snap out of it.” Once, during group supervision, a student commented that her patient had to “just suck it up.” As her peer challenged the unempathetic suggestion, she said, “What else is there to do? You can’t change the other person’s opinion.”

The discussion ensued that this isn’t a friend who had an argument with their partner, and you’re trying to be encouraging. Chances are, the patient would likely have “just” done whatever if they could. This is someone whose conflict was significant enough to draw them to treatment. Perhaps they need to learn how to suck it up/do it/snap out of it because their approaches weren’t working.

If someone has ever told you to “just calm down” when you’re really upset, you know a patient may receive this poorly. The word “just” implies minimization of the problem and maybe even weakness, and understandably can elicit negative projections towards the provider. Clearly, it’s also indicative of “I’ve got nothing to offer.” This jeopardizes faith in the provider, in turn diminishing the therapeutic alliance, which is well-documented (e.g., Ardito & Rabenillo, 2011; Fluckinger et al., 2018) as one of the most important components of treatment.

Not being sure how to navigate certain situations is part of the learning curve and should be seen as an opportunity to refine one’s skills. If a therapist finds themselves thinking, “There’s not much we can do about that,” or “They just need to...” it’s likely best to withhold commentary and seek supervision on the situation. Patients are struggling to just find a solution and know they can’t hit rewind. They’re in therapy precisely because they can’t do this and are hoping for alternative resolutions.

Disclaimer: The material provided in this post is for informational purposes only and not intended to diagnose, treat, or prevent any illness in readers. The information should not replace personalized care from your provider or formal supervision if you’re a practitioner or student.

LinkedIn and Facebook image: Photographee.eu/Shutterstock

References

Abbas, J., Aqeel, M., Jaffar, A., Nurunnabi, M., & Bano, S. (2019). Tinnitus perception mediates the relationship between physiological and psychological problems among patients. Journal of Experimental Psychopathology, 10(3). https://doi.org/10.1177%2F2043808719858559

Ardito, R. B., & Rabellino, D. (2011). Therapeutic alliance and outcome of psychotherapy: Historical excursus, measurements, and prospects for research. Frontiers in Psychology, 2, 270. https://doi.org/10.3389/fpsyg.2011.00270

Flückiger, C., Del Re, A. C., Wampold, B. E., & Horvath, A. O. (2018). The alliance in adult psychotherapy: A meta-analytic synthesis. Psychotherapy. Advance online publication. http://dx.doi.org/10.1037/pst0000172

Guitton, M. (2006). Tinnitus and anxiety: More than meets the ear. Current Psychiatry Reviews, 2(3), 333-338.

Kehrle H., Sampaio A., Granjeiro R., de Oliveira T., & Oliveira C. (2015). Tinnitus annoyance in normal-hearing individuals: Correlation with depression and anxiety. Annals of Otology, Rhinology & Laryngology, 125(3), 185-194. doi:10.1177/0003489415606445

Leutenberg, E.A. & Liptak, J.J. (2012). Coping With Difficult People Workbook. Whole Person Association, Inc.

Moon, K., Park, S., Jung, Y., Lee, A., & Lee, J. (2018). Effects of anxiety sensitivity and hearing loss on tinnitus symptom sensitivity. Psychiatry Investigation, 15(1), 34-40. https://dx.doi.org/10.4306%2Fpi.2018.15.1.34

Pattyn, T., Van Den Eede, F., Vanneste, S., Cassiers, L., Veltman, D.J., Van De Heyning, P., & Sabbe, B.C.G. (2016). Tinnitus and anxiety disorders: A review. Hearing Research, 333, 255-265.

Shannon, Joseph W. (2019, October 25). Character flaws: How to understand and navigate relationships with high conflict clients. Brattleboro Retreat, Brattleboro, Vermont.

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