There is much evidence to support the benefits of the main therapeutic approaches provided by trained, licensed psychologists. It’s clear that many (hopefully most) clients genuinely benefit from their therapy journey. Nevertheless, even the most ethical and well-researched therapeutic intervention can be actively harmful in the hands of an improperly trained therapist. And some ‘therapy’ tools and techniques are neither ethical nor well-researched, and can be dangerous.
Even evidence-based therapeutic intervention can be ineffective or harmful
While many other fields routinely examine adverse effects, psychotherapy research tends to focus only on the benefits. As ethical clinicians, we need to consider the potential harm of any treatment, and weigh the benefits against the possible costs.
Therapy harm is difficult to measure. It may be subtle. It may be primary or secondary (family, friends, or colleagues of the patient may be indirectly harmed). Also, it tends to depend on subjective self-reports. But it’s not impossible to determine.
There are interesting meta-studies out there that have tried to quantify direct harm resulting from therapy. Research suggests that talk therapy can also be indirectly harmful. If the therapy is inappropriate or ineffective, it becomes a waste of the client’s time and money.
According to the British Psychological Society, approximately 10 percent of all therapy patients experience adverse effects. In other words, they’re worse off than they were before therapy.
Adverse effects include current symptoms getting worse or new symptoms emerging. For example, some clients presenting with trauma may be further traumatized. Other clients may experience negative changes in their occupational (work) functioning or their interpersonal (relationship) functioning. Some clients may develop ‘therapy dependence’. They feel less self-efficacy over the course of the therapy rather than more. Some may begin to exhibit self-harming behaviors and even suicidal ideation.
Therapy needs to offer relief
It’s important to note that over the course of a therapy, things might get worse before they get better. Change is hard, and brings up pain and conflict. Part of being a good therapist is being comfortable holding our clients as they grapple with their pain and face difficult changes.
However, the overall results of therapy need to be beneficial. There should be symptom reduction and positive shifts (seen by both therapist and client) over a reasonable amount of time. What constitutes a ‘reasonable’ amount of time depends very much on the individual context of the individual therapy. This is why it’s so important to seek client and supervision feedback.
Can a therapeutic intervention be dangerous?
The empirical data shows that certain types of therapy are actively harmful. Yet some of these are actively taught and practiced. A current list of discredited techniques published by the British Psychological Society, and published by an investigation conducted by the American Psychological Association (APA), includes:
- Critical incident stress debriefing (specifically group CISD, group CISM) – a group process led by a facilitator/psychologist, which is intended to debrief stressed individuals after a traumatic event has occurred. Unfortunately, this therapeutic intervention doesn’t seem to reduce the likelihood of developing PTSD, and may make things worse by re-traumatizing the people involved. (This does not apply to all kinds of trauma work following a traumatic event.)
- Facilitated communication – where a person who is physically or intellectually unable to communicate effectively, is “assisted” or “supported” to type words, point to pictures or symbols, or otherwise communicate, by another person/facilitator. Studies show that the facilitator consciously or unconsciously controls the communication and these techniques may even constitute a form of abuse. (This is not the same as using technological resources such as speech synthesisers for people who are unable to talk)
- Recovered-memory techniques – hypnosis, guided imagery, and even drugs are used to ‘recover’ memories, usually of childhood sexual abuse. There is no reliable or scientific way to distinguish whether recovered (buried) memories are true or false, and studies show very poor outcomes for patients subjected to these techniques, as well as secondary harm to their families and significant people in their lives. (This is not the same as clinical hypnosis itself, which is a valid and well-researched clinical procedure used by trained professionals to facilitate other therapies.)
- Conduct disorder boot camps (“scared straight” programs) – children as young as eight years old are placed in behavioral training camps to scare, shock, and coerce them into better behavior. There is no scientific evidence supporting this kind of punitive ‘rehabilitation’.
- Attachment therapy involving physical restraint – sometimes used for adoptive/foster children who demonstrate poor attachment and disobedient behavior. Different forms of ‘rebirthing’, holding, and physical restraint of the children subjected to this pseudoscientific intervention have led to documented cases of serious maltreatment and even death.
- Conversion therapies – these techniques attempt to eliminate same-sex attraction or change someone’s sexual orientation. Ranging from talk therapy and prayer to exorcism, food deprivation or even physical abuse, research has shown these kinds of therapies to be both ineffective and harmful.
Any therapeutic intervention is intended to cause (positive) change. Thus it’s not surprising that therapy techniques also have the power to do harm. However, when it comes to a therapeutic intervention by a psychologist, there may be a blind spot on the part of both therapist and client to potential negative side effects. Yet, we need to be aware that therapy doesn’t work for everyone.
We as therapists may have the best intentions in the world, but it’s important to acknowledge that even our best-intentioned actions within a therapeutic relationship may have unintended, harmful consequences to our client and/or the people around our client.
You can read more about the ethics of good practice in Part 2.