Can psychotherapy cause harm? When does it become harmful for clients? These are rarely examined questions, and no psychotherapist or counsellor sets out to cause harm in practice. However, it can happen. This summarises our recent training workshop with Dr Phil Mollon, who faced this issue head on for us and asked who was brave enough to question their own practice.
Causing harm through psychotherapy
When we talk of harm its easy to imagine gross misdemeanours, and yet harm which arises when therapy is practiced ‘well’ (meeting all guidelines) can cause just as much damage to the client. Essentially this occurs when the client experiences your good intentions as damaging in some way.
Dr Mollon looked at this issue of harm in psychotherapy from a number of different angles, gave examples of harmful therapy from his career, as well as asking the question of why this important issue isn’t more widely discussed. Why is it never openly stated that therapy can not only be lacking in efficacy, but can even exacerbate clients presenting issues?
The client’s view of therapy
There are obvious ways in which therapy can become perverted in the service of destructiveness towards the client – making hurtful interpretations, aggressively imposing a theory on the client or being disparaging of other resources the client may seek which the therapist does not favour. But these are not the focus of this investigation.
We often think that what we as therapists try to offer is in the best interests of the client. But do we think about how the client might view things differently? Here are a few common scenarios where the client’s perception of the therapy process may be different to that of the therapist.
- The long-term client – A client in long term therapy may feel stuck or that they are no longer progressing. They might think about leaving therapy and talk about this with their therapist. The therapist could react in a number of ways which could be helpful, but what if they believe so stringently in what they are doing that they can’t see the client’s point of view? Telling the client that ending therapy would be a defensive escape from a difficult issue arisen in therapy might dismiss the lived experience of the client in the room and make them feel unheard and ignored, creating resentment in the therapeutic relationship.
- The misunderstood CBT process – CBT therapy can be incredibly useful in helping clients to manage their experiences and emotions, but it can often be missold as a ‘cure’. Take, for example, a traumatised client who is taught anxiety management by their CBT therapist who spends no time addressing the trauma itself. As time passes and the client begins to re-experience the trauma, they may feel they have failed, thus experiencing harmful effects from a treatment that was promised to end their suffering.
- The excessive treatment – Imagine a psychoanalyst whose training has taught them that analysis 5 times a week is the only approach that works, they’ve experienced it themselves and seen the benefits and so believe it to be true. But to the client this could seem excessive, as invasive in their life, as all pervasive with no escape and potentially financially damaging.
- Reemerging trauma – Clients with a past experience of trauma might attend therapy in order to resolve feelings about it. The therapist, in order to understand the experience or wanting to work through it may address that topic in session, but in talking about that experience the client may in turn feel re-traumatised by a therapist with no understanding of their current needs.
None of these examples (and there are many more) are intentionally harmful, and yet we can see that from the point of view of the client, where they have sought help from a trained professional in order to feel better, they could have left the experience feeling worse.
Research into unintentionally harmful psychotherapy
There is very little research into the harm that properly executed therapy can cause. This is an unusual anomaly for a medical field, as in every other area research is abundant into both efficacy and failure of all treatment options. However, sparse though it may be, the research does exist and it indicates that psychotherapy is often not very effective in alleviating distress, and can leave some clients in a worse state.
Harmful side effects from psychotherapy
In their 2009 paper, The elephant on the couch – side effects of psychotherapy, Berk & Parker raise a few interesting points.
Loss of autonomy
Firstly, although the idea of clients developing an internalised therapist is often seen as a positive outcome of therapy, they posit that “The longer any patient attends a psychotherapist, irrespective of how therapeutic the therapy, the patient risks contracting their independent capacity to make decisions (self-mastery)… distanced from the capacity and risks inherent in making their own mistakes in the real world, and more importantly learning from them”. There is, of course, no malice intended in this interaction, and indeed a client proudly proclaiming ‘I asked myself what you would say’ can be seen by the therapist as a positive sign of the client taking time to examine their actions outside of the therapy session, and yet on being shown the flip side of the coin we see that it too is equally valid. (Australian and New Zealand Journal of Psychiatry 2009;43:787-794)
Reliance on negative coping strategies
The process of therapy can also be taxing on the emotional resources of the client. If a client has unhealthy coping strategies for negative or stressful situations such as substance misuse or disordered eating, then by engaging in therapy they might find themselves overwhelmed, and turning to these behaviours in order to comfort themselves to cope with what therapy has brought up for them. (Dishion TJ, McCord J, Poulin F. When interventions harm. Peer groups and problem behaviour. Am Psychol 1999;54:755-764)
The end of therapy
It is also important to note that even in therapy where no harm has been experienced by the client, there can harmful outcomes when it ends: “Over time, long-term bonds of attachment to the therapist make termination of therapy a traumatic life event, particularly if transference has been an important therapeutic component.” (Berk, Parker. The elephant on the couch – side effects of psychotherapy. Australian and New Zealand Journal of Psychiatry 2009;43:787-794)
The statistics on therapy’s success
The dismaying truth about psychotherapy is that sometimes it just isn’t very effective despite the therapists best intentions and extensive training. Overall, outcome research gives quite pessimistic results, suggesting that only 60% of clients benefit from therapy, and 15-24% of adolescents leave therapy in a worse state than when they started (Lambert).
The danger of therapeutic goals
Setting goals is a great way to structure the therapeutic relationship, but whilst the overall goal of therapy is to reduce internal obstacles to wellness, some goals may implicitly promise illusions that cannot be fulfilled.
Goals, although a great way to set a target to work towards, can cause harm to clients who experience feelings of failure. There is a danger that they may feel internal or external blame “for not meeting intervention targets, have been held to increase helplessness and self-blame, and so undermine self-efficacy”. (Marlatt GA, Gordon JR. Relapse prevention: maintenance strategies in the treatment of addictive behaviours. New York, NY: Guildford Press 1985)
Goals to avoid in therapy
Illegitimate goals for therapy (those that could be said to cause harm) might include illusory formulas for happiness, forcing the therapist’s world view onto the client or selling the idea of the therapist knowing best. Legitimate goals of therapy should therefore be client-led – to help the client resolve what they deem to be internal obstacles to achieving goals and satisfying desires in relationships and work, and to help counter unrealistic illusions about what life should be. Therefore goals should be helping to facilitate a shift from neurotic misery to ordinary unhappiness, to paraphrase Freud.
Avoiding harm in psychotherapy
So, the research shows that unintentional harm in psychotherapy is a very real possibility. What steps can we take to mitigate this?
Accept that psychotherapy can be harmful
If we as professionals can accept the unpalatable truth that we may cause harm to our clients, then we can take steps to minimise that harm.
“However painful it may be, it is important for those of us who are psychotherapists to recognize that we have all likely harmed one or more of our clients… we would venture to guess that all experienced psychotherapists have, at one point or another in their careers, failed to meet the most basic and ethically important principal guiding the profession: First, do no harm.” (Castonguay et al. 2010. Training Implications of Harmful effects of psychological treatments. American Psychologist, 65(1), 34-49)
Seek feedback from your client
With acceptance comes the ability to minimise harm. So how do we go about this? We have seen that the most common method of harm is to impose upon the client, and so feedback must be a key component of a positive therapeutic relationship. Regularly reviewing the work, checking goals and simply asking ‘am I helping’ can make a lot of difference to a client – offering them power in an unbalanced relationship and control over their treatment.
Maintain flexibility in therapy
Effective treatment will likely not have a singular focus but will balance an exploration of the traumatic past with an intention for a positive future and methods to explore obstacles and amend as necessary. It will be flexible and client-led, and will be open to acknowledgment of the therapist’s imperfection.
Understand the therapeutic role in the relationship
Therapists carry a heavy burden, an expectancy for them to ‘fix’ the unfixable, but with this comes an assumption that we can fix everyone, and that it is our job to fix. In reality therapy is about becoming a fellow traveller – taking part of the client’s journey with them and helping them to explore and understand their world for themselves. We might get it wrong, but we are human, and in owning our mistakes we can perhaps avert harm, and provide a lesson instead.
Often it is what the therapist does not do that is most important – does not presume to know, does not try to fit the client into a theory or dogma, does not assume the position of authority. By balancing this negative capability with active enquiry and appropriate concern we might just minimise our potential to harm the client enough to help them to grow.