Jan

5

2018

Can Therapy Make Things Worse?

Therapy is a force for good, but it needs to be acknowledged that sometimes therapy can make things worse. This is a challenging read for therapists and counsellors, but an important one nonetheless. We can only implore you to read on and gain a better understanding of how sometimes therapy can be damaging. This article was written by Dr Philip Cox (C.Psychol, Psych. D).

When therapy can make things worse

Brighton Therapy Partnership hosted Dr Phil Mollon’s potentially controversial seminar, entitled “When Psychotherapy is Harmful…” in June, 2017.

Why controversial? It’s because few therapists openly discuss relevant research or take part in trainings that explore the extent to which psychotherapy can be experienced as harmful. The following article seeks to explore and to expand upon Dr Mollen’s seminar, in order to broaden the focus with regard to understanding harmful psychotherapy, and how therapy may make things worse.

All therapists should understand that therapy can be damaging

Strupp, Hadley, and Gomez-Schwartz’ (1977) seminal work, Psychotherapy: For better for worse is an exploration of how one client improves and another gets worse, as “an absolute necessity if the field is to advance … [and] a challenge that must be met in years to come” (p. 12). Four decades later, it seems that only a few training institutions or speakers such as Dr Mollon are willing to openly engage with the possibility that a significant number of clients report feeling harmed by attending therapy.

It’s not just negligent therapists who cause harm

During the seminar, Dr Mollon looked at negligent therapy and professional naiveté, which can lead the well-meaning therapist to cause harm rather than engendering positive change when working with clients. Negligent therapy or malpractice, such as sexual relations with clients, is clearly unacceptable within the codes of ethics and thus was not explored here.

The notion that a group of negligent therapists deliver bad therapy avoids the idea that sometimes any therapist may deliver therapy that a client perceives as harmful. Giving further consideration to Dr Mollon’s seminar of when therapy perceived as harmful is delivered by well-meaning therapists, and crucially within a professional a code of ethics helps us take on board the significant number of clients who report experiencing their therapy as harmful.

Negligent, professionally naive or well-meaning therapists engendering harm, it seems to be that it is important to recognise that “[w]e are the bad therapists too. If there is someone who says he has never done bad therapy (whatever that is), then this is someone who is likely to be doing bad therapy (whatever that is)” (Shohet, 2017, p. 70).

It seems disingenuous to say only other therapists deliver therapy that clients experience as harmful and this serves to reinforce how the topic gets pushed to the side-lines by those with insight into the topic; therapists. Yet, curiously, the dilemma of when therapy that is practised well enough still leads to clients feeling harmed seems difficult for many therapists to acknowledge. Because this is a difficult topic to cover, if you’re here reading this then you should at least pat yourself on the back for engaging with such a challenging issue.

Exploring when psychotherapy goes wrong

Dr Mollon asked three profound questions to explore the dilemma of when clients report their psychotherapy as harmful:

  1. Can psychotherapy cause harm?
  2. When does therapy become harmful for clients?
  3. Why isn’t this issue discussed more widely?

Below we will unpack how each question relates to the field of psychotherapy, and what it may mean for a more informed view of what and how we practice in the name of therapy.

Definitions of harmful therapy vary and so impact upon how we understand the issue. For example, within sessions it is likely that clients may experience increased distress precisely because difficult issues are explored. Therefore, a suitable definition of harm is, “a negative effect [that] must be relatively lasting, which excludes from consideration transient effects … [such as in session anxiety or between session sadness, and] must be directly attributable to … the therapeutic experience or intervention” (Strupp et al., 1977, pp. 91-92).

 Can psychotherapy cause harm?

After critiquing the “branding” of therapy into separate therapeutic modalities, Dr Mollon narrowed his focus to what he suggests works in therapy. This included Eye Movement Desensitisation and Reprocessing (EMDR) and Psychoanalytic Energy Psychotherapy (PEP).

Dr Mollon developed PEP, which is grounded in the psychoanalytic tradition, because “it seems to me an obvious conclusion that a clinician wishing primarily to help his or her clients will draw upon effective [integrative] components from different traditions in order to facilitate the individual’s idiosyncratic journey of emotional healing.” This article seeks to broaden Dr Mollon’s discussion through the lens of what the research tells us about the extent to which clients say they feel harmed by attending psychotherapy.

The size of the problem

To expand upon when psychotherapy is harmful, it helps to appreciate how much harmful psychotherapy is reportedly out there. Decades of studies report that on average, individuals receiving psychotherapy are 80% better off post-treatment than untreated individuals (American Psychological Association, 2012).

Yet, irrespective of a client’s presenting issue(s), the therapeutic modality applied or the therapy’s context within the Western world, the research consistently shows around 10% of people attending therapy report experiencing therapy as harmful and making things worse. This statistic increases for groups such as adolescents, the LGBTQR community and minority groups.

Therapists make the most complaints about therapy

Curiously, for therapists reporting on their personal therapy, the figure ranges between 27%  to 40% (Williams, Coyle, & Lyons, 1999; Macaskill & Macaskill). What may surprise therapists is that across the registration bodies, the largest group of complainants are typically therapists. For example, Raffles (2015) reports that 71% of complaints made to the British Association of Counselling and Psychotherapy (BACP), are made by people associated with counselling.

The largest number of complaints about therapy come from other therapists.

Similarly, half of the complaints made to the Health Care and Professions Council (HCPC) against practitioner psychologists, are made by professionals. The situation is similar for the United Kingdom Council for Psychotherapy (UKCP). Therapists may therefore have insights to help us understand how and when therapy may become harmful clients.

Damage caused in public sector therapy

While it is difficult to know what the statistics mean in actual numbers of real people, because many clients attend private therapy, it is important to consider therapy practised in the public sector. This offers an indication of how many people report experiencing therapy as harmful.

Improving Access to Psychological Therapies (IAPT) treated 1 million people (2009-2012) with a recovery rate of 45% (Department of Health, 2012). From the 97% of completed outcome questionnaires, IAPT reports the current national client deterioration rate as 6%, or 54,000 people (Clarke, 2016). IAPT is due to scale-up to treat 1.5 million people annually (Clarke, 2016), which could translate into 900,000 people feeling harmed by attending public sector therapy.

Is IAPT making things worse?

IAPT’s data introduces some interesting ethical and moral dilemmas. While operating within the codes of ethics of the mainstream regulatory bodies (e.g. BACP, HCPC), IAPT’s own data shows the programme is not working for most clients. If a majority of clients do not benefit from a “branded” therapy, is it ethical to continue treating the minority with the same mechanistic intervention? As a profession and as a society, what theoretical, ideological or political choices drive how we spend national funds? Also, perhaps IAPT represents one mechanism by which therapy can become harmful, yet remains in operation. Further, IAPT can illustrate how therapy can inadvertently introduce or even perpetuate the stigmatisation of marginalised social groups.

However, the research is clear. These issues appear irrespective of the presenting issue, therapeutic modality or the therapy’s context. While IAPT helps illustrate the issues, to point a finger at IAPT is to miss the key point; the issues around potentially harmful therapy are evidenced across the field of therapy. This means that to speak of an identifiable group of negligent therapists parallels the topic. It also limits a discussion that any therapist may deliver therapy that a client perceives as harmful. This highlights the process whereby we avoid talking about when and how therapy becomes harmful for clients, or miss opportunities to attend lectures that explore this underreported and underexplored area of practice.

When does therapy become harmful for clients?

Therapy seems at risk of becoming harmful when the therapist seems unaware of how the client experiences the process. Research suggests that many therapists have considerable difficulty recognising when therapy becomes harmful and may be making things worse (Hatfield, McCullough, Frantz, & Krieger, 2010).

For instance, Walfish, McAlister, O’Donnell, and Lambert (2012) reported that “25% of mental health professionals viewed their skill to be at the 90th percentile when compared to their peers” (pp. 644-645). None self-assessed as below average. As this is statistically impossible a significant degree of self-deception seems evident. In my own research of the topic, participants who were also seasoned practitioners often said, ‘I’ve never had a complaint launched against me so I’m assuming that’s the concrete way of knowing that I do not practice therapy experienced as harmful’. This is how we gaze at other therapists and look at the content rather than the process of therapy, and how this narrow perspective limits a broad discussion.

Could it be that therapists are suffering from the Dunning-Kruger Effect en masse?

The dichotomy of therapeutic action

Research just published brings together many of the points within this discussion (Swift, Tomkins, & Parkin, 2017). When interviewed about their experiences of therapy, the clients said some of the same therapist actions could be both helpful and hindering. For example, times when the therapists were described as listening, trying to offer empathy, and structuring the session were rated as some of the most helpful and the most hindering moments. This was broadly the clients’ experiences irrespective of theoretical orientation. This illustrates the delicate balance that therapists must find while conducting therapy. To find this balance “it seems that a high level of therapist attunement is needed” (Swift et al., 2017, p. 1554). In relation to Dr Mollon’s seminar, it seems important to recognise that all therapists make errors. Perhaps the success of a session does not depend on whether errors are made, yet more on the frequency of mistakes and how quickly therapists and clients are able to co-repair them.

Why isn’t this issue discussed more widely?

In my research, participants who were also therapists spoke of our profession’s public ‘name and shame’ or ‘name, shame and struck off’ process. The professionals spoke of their day-to-day struggle to balance their concerns around a perceived right way to practise therapy, versus a perceived wrong way to practise therapy. A key tension was the participants’ fear of being publicly held to account for their choices in a profession that all acknowledged is inherent with risks. In short, they said the more scared they become, the less creative they are. These participants, in a profession where the codes of ethics value openness and honesty, said they are fearful.

Fear of practice in the public sector

This concern was particularly pronounced for IAPT practitioners. This suggests a potential paradoxical outcome for the implementation of codes of ethics that are intended to reduce the upward trend in complaints, yet may actually restrict an open discussion of therapy perceived as harmful because of the fear of being shamed. This shaming process could partially explain why the topic of harmful therapy is not thus discussed more widely.

Wrongdoing is a taboo topic

Revisiting the notion of practitioners having difficulty recognising client deterioration (Hatfield et al., 2010), or generally lacking realistic self-assessment skills (Walfish et al., 2012), one hidden aspect emerged in my research (Cox, 2016); few participants felt that harm is openly shared among professionals. Those few who did voice the issue almost invariably spoke of private shame. This seems paradoxical in a field where the practitioner’s intentionality is to work openly and transparently with others. Perhaps there is a tension that we may be asking clients to engage in therapy in ways that we as professional providers of therapy seem less able to do.

The right approach to wrongdoing

To counter defensive practices, we need to train practitioners that it is alright to disclose their errors. We also need to help therapists feel free to disclose errors, and only then are we free to make them, and reflect upon them.

Therefore, the key recommendation from Dr Mollon’s seminar is to introduce the topic of harmful therapy or ‘unintended harm’, into training programmes and workshops. This could help professionals to integrate theory and field practice. Without specific training, some practitioners could continue making things worse for clients, and may not even recognise that they are doing harm.

Understanding when therapy may make things worse is vital to ensure we don’t let our clients down

Also, the word ‘harm’ itself might mean different things to different people, which underlines why transparency is so crucial. Dr Mollon’s seminar was a place to transparently explore the issues. The point is emphasised by Corrie and Lane (2010), who consider “ethical and effective practice is dependent upon practitioners keeping themselves informed about theoretical and empirical developments” (p. 88). This is one reason why attending Dr Mollon’s training is so important. A second reason is to extend Dr Mollon’s seminar by talking about the grassroots work of the Psychotherapy and Counselling Union (PCU).

Psychotherapy and Counselling Union

The PCU, whose motto is ‘Standing up for Therapists, Standing up for Therapy’, offers support to members who have received a complaint. In my role as the lead for complaints, it feels sad that in a profession committed to openness, honest and transparency, all of our members who have been involved in a complaints process feel damaged by it. This is irrespective of the professional registration body, which suggests it is a regulatory issue rather than relating to any one professional body. I suggest that it is also a therapy issue because many complainants say they were not heard during the process, and so experience further harm.

Personally, I find it sad that as a profession we are dedicated to wellbeing yet seem unable to explore when therapy becomes harmful, or deal with the process rather than the content of when clients feel harmed. It feels sad that the Professional Standards Authority, the regulator which oversees the other regulators (e.g. BACP, HCPC, UKCP) considers, “The confrontational nature of proceedings and the stress that hearings engender can affect the health and wellbeing of all concerned … [and] runs counter to our growing understanding of the situations where things go wrong, and the inter-connections” (PSA, 2016, p. 1).

The Union is open to all therapists. We offer support and guidance about what to do if you receive a complaint. We have supported many members during the long proceedings and at complaint hearings, and we have helped members to achieve many outstanding outcomes by simply helping therapists to explain what occurred from a therapeutic rather than a legal perspective. Some quotes are listed on our website, as well as the social justice activities and campaigns that seem relevant to psychotherapy and its practice (PCU, 2017). When requested, we can visit organisations to talk about our work and explore how the PCU could support you. This feels like a great extension to the work of Dr Mollon who has been brave enough to talk about the elephant in the therapy room – the controversial topic of harmful therapy, and in this blog, what to do when therapy becomes harmful so that the clients and our own wellbeing can be enhanced in the service of the work.

References
  • Clark. D. (2016). The improving access to psychological therapies (IAPT) programme: Background, strengths, weaknesses and future direction. Keynote, Division of Counselling Psychology annual conference, 8th July 2016. Brighton, UK.
  • Corrie, S., & Lane, D. A. (2010). Constructing stories, telling tales: A guide to formulation in applied psychology. London: Karnac.
  • Cox, P. K. (2017). Opening Pandora’s box: Unintended harm in the consultation room. Thesis in fulfilment of Professional Doctorate in Counselling Psychology, University of Surrey, UK.
  • Department of Health. (2012). IAPT three-year report: the first million patients. London:   DoH.
  • Hatfield, D., McCulloch, L., Frantz, S. H., & Krieger, K. (2010). Do we know when our client’s get worse? An investigation of therapists’ ability to detect negative client change. Clinical Psychology and Psychotherapy, 17(1), 25-32.
  • Macaskill, N. D., & Macaskill, A. (1992) Psychotherapists-in-training evaluate their personal therapy: Results of a UK survey. British Journal of Psychotherapy, 9(2), 133–138.
  • Mollon, P.  (2017). When Psychotherapy is Harmful… Seminar presented at Brighton Therapy Partnership, June 24th, Brighton, UK.
  • Professional Standards Authority. (2016). Regulation rethought: Proposal for reform. London: Professional Standards Authority.
  • Psychotherapy and Counselling Union. Website. https://pandcunion.ning.com/
  • Raffles, K. (2015). Working with ethical dilemmas in supervision. Presentation at, the Psychologists Protection Society’s Annual General Meeting & CPC event, 11thSeptember 2015. London, UK. (accessed 5th May 2017).
  • Shohet, R. (2017). Exploring the dynamics of complaints. Self & Society, 45(1), 69-71.
  • American Psychological Association. (2012). Recognition of psychotherapy effectiveness. Washington, DC: American Psychological Association.
  • Strupp, H. H., Hadley, S. W., & Gomes-Schwartz, B. (1977). Psychotherapy for better or worse. New York: Jason Aronson, Inc.
  • Swift, J. K., Tomkins, T. A., & Parkin, S.R. (2017). Understanding the client’s perspective of helpful and hindering events in psychotherapy sessions: A micro-process approach. Journal of  Clinical Psychology, 73, 1543-1555. DOI: 10.1002/jclp.22531
  • Walfish, S., McAlister, B., O’Donnell, P., & Lambert, M. J. (2012). An investigation of self-assessment bias in mental health providers. Psychology Reports, 110(2), 639-644.
  • Williams, F., Coyle, A., & Lyons, E. (1999). How counselling psychologists view their personal therapy. The British Journal of Medical Psychology, 27(3), 545-555.

3 Comments

  1. Dane Pestano on 6 February 2018 at 5:31 pm

    Your blogs are great. Ever thought of sharing them to other sites. Check out Brighton & Sussex Mind Body Spirit and raise your profile locally. We are looking for bloggers and its free for one blog a month.

    Regards
    Dane

    • Brighton Therapy Partnership on 7 February 2018 at 8:00 am

      Hi Dane, thanks for the heads up. We don’t share our blogs anywhere else I’m afraid, but keep up the great work with your website.

  2. Murad on 28 February 2019 at 3:08 pm

    Excellent and thought provoking piece. I often argued along similar lines when I used to work in acute wards, especially for certain profiles of people (CPTSD, psychosis, minorities etc). ‘Primum non nocere’ was often ignored or unheard of as a baseline ethic. Some patients suffered greatly, thanks to the ‘care plans’ enacted.

    One thing I noticed here-did you mean 90,000 and not 900,000? Because a 50% increase in overall treatment cases surely would indicate a 50%ish increase in rates of people feeling harmed.
    “Improving Access to Psychological Therapies (IAPT) treated 1 million people (2009-2012) with a recovery rate of 45% (Department of Health, 2012). From the 97% of completed outcome questionnaires, IAPT reports the current national client deterioration rate as 6%, or 54,000 people (Clarke, 2016). IAPT is due to scale-up to treat 1.5 million people annually (Clarke, 2016), which could translate into 900,000 people feeling harmed by attending public sector therapy

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