In part 1 of this article about therapeutic interventions, I discussed the importance of clinically valid interventions. In this second part, I outline necessary steps that clinicians should take in order to make sure their work is not harmful.
The client won’t know what to expect from therapy. Our clients might have ideas about what kind of therapy is useful for them. However, most likely they will depend on us to lead the way. If we’re a qualified, licensed mental health practitioner, our clients rightfully expect us to have the proper training, experience, and tools to help them.
So how can we, as clinicians, be sure that we’re not causing damage? While it’s important to accept that we are all-too-human and imperfect, there are a few things we can do to protect ourselves and our clients from harmful or bad therapy.
1. Specialize what we offer (within our scope)
Psychologists might receive very general training. Many of us were trained in under-resourced systems. We were ‘thrown into the deep end’ the moment we completed our internship, or even during our internship.
Where there’s vast need and limited resources, such as in many developing countries, it’s the norm for newly trained psychologists to see a diverse patient population. We have worked with patients from all culture and all ages. We have met patients presenting with a wide range of problems including severe psychopathologies. Additionally, we may have done all kinds of assessments and many types of therapies. It’s not uncommon for a psychologist to be expected to offer group therapy, couples and individual therapy, play therapy, art therapy, and more. Therefore it’s not surprising that we might feel that our scope is vast and we can take on anything.
As an ethical clinician, it’s often helpful to screen our clients and we should refuse certain referrals if we believe the client isn’t a good fit for us and our skills, or we’re not the right therapist for the client. The best therapist is not one person.
Sometimes it’s clear that the client would better benefit from seeing someone who is more experienced or who has specialized training to deal with specific issues. If so, we need to refer in the best interests of ourselves and our clients.
2. Education is key – expand our knowledge
Simply collecting our annual continued professional development (CPD, CME) points isn’t really enough to keep up to date with our constantly changing field. Keep in mind that all humans are subject to confirmation bias. We naturally and unconsciously select information that confirms our existing attitudes and beliefs, including our clinical perspective. Therefore, we need to challenge ourselves by stepping outside our comfort zone and searching for contrasting viewpoints.
We need to read widely, complete accredited courses, attend conferences, and engage in peer learning to keep updating and expanding our knowledge
3. Interrogate what we think we know
Science-based therapies can be harmful, so it’s definitely important to carefully consider the best needs of the client. However, psychologists may go in the opposite direction of trying too hard to avoid a harmful outcome. Which has the end result of a client population who have been denied therapy without good reason.
For example, psychologists and other mental health professionals used to believe that grief counseling for ‘normal grief’ was counter-therapeutic. This widely-held idea went against clinical common sense, yet somehow became part of the scientific literature. It seems that some psychologists, researchers, and scholars in the field simply read, accepted, and then cited the conclusions in a particular abstract without ever reading the study for themselves. Others in the field then cited those papers and so it went on.
The American Psychological Association (APA) later found that the whole premise was based on a single article published in 2000, which originated from a student dissertation using a statistical method that was never properly reviewed.
There’s now a solid body of scientific literature that supports the value of therapy for grieving clients. Yet, while researching this article, I found this erroneous idea (that grief-based therapy causes harm) is still being propounded even in well-known psychology blogs.
Another example of a false, yet widely-held set of clinical ideas can be found in the area of Dissociative Identity Disorder (DID). Myths around this complex, post-traumatic disorder include ideas that DID is a rare, overdiagnosed, fad diagnosis, that it’s a form of borderline personality disorder, or that it’s iatrogenic (induced by clinical intervention/treatment). Therefore, many mental health professionals incorrectly believe that specialised DID treatment is harmful or leads to the development of further personalities.
All of this has meant that clinicians haven’t sought specialist training in DID treatment, and patients with DID have been under-diagnosed and under-treated. In reality, DID is a trauma-based disorder that responds well to targeted trauma intervention as per the current standard of care outlined by the International Society for the study of Trauma.
To be an ethical psychologist, we have to cultivate an open mind and always hold the possibility that what we believe to be true may be entirely incorrect.
4. Seek supervision
We are all human and we all have blind spots. This means that no matter how hard we try, or how much we study, we will make mistakes and head in the wrong direction with certain clients in certain therapies.
This is where supervision makes all the difference. It keeps us on the right track. Supervision protects us and our clients. It helps us to grow and develop.
Group supervision and individual supervision both offer wonderful opportunities for learning and feedback. Ideally, we should engage with supervision regularly. We should also seek out specific supervision when we need to, such as when we’ve studied a new technique and are learning to apply it.
5. Place the client at the centre of therapy
This may seem like a no-brainer but it is always worth repeating. No matter how clever and well-trained we may be, “it is the relationship that (holds and) heals” (Irvin D Yalom, in Love’s Executioner and Other Tales of Psychotherapy).
It doesn’t matter how evidence-based our therapy techniques might be, if we offer them with underlying indifference to our client. Under such circumstances, therapy is unlikely to work. Our clients can sense whether or not we genuinely care about them.
When we truly prioritize the wellbeing of our clients, we observe them closely. We make it our highest priority to offer a safe, sensitive, caring, and non-judgemental space for our clients.
It’s as well to keep in mind that the UAE is a melting pot of many different cultures. Hence, we need to be mindful of cultural differences that might make some of our questions offensive to our clients.
6. Seek client feedback
Research shows that clients and therapists frequently have different perspectives on how helpful a session was. Or, what the overall progress and efficacy of the therapy is. We need to have some kind of formal or informal feedback process in place. We need to make it a practice to check in with our clients on a regular basis. When we elicit honest client feedback, we can do our best to address any issues or misunderstandings that arise. This puts us on the same page as our client.
7. Practice self-care
Without a solid foundation of self-care to maintain our own health, we may find ourselves ‘unfit’ for therapy. Although we all talk a lot about self-care to our clients, there are many personal and professional reasons why we might feel under pressure to see as many clients as possible. Or, why we might practice good self-care in one area of our lives but not in another.
So it can be helpful to remind ourselves that it’s our ethical duty to take care of our overall well-being. What constitutes self-care looks different for everyone, and changes over time. We are all unique individuals who have different capacities, strengths and energies, and these ebb and flow at different times.
In this article I outlined how therapy can indeed be harmful or helpful. I also discussed ways to protect ourselves and offer our best, most ethical practice to our clients. We can only utilize our therapeutic interventions to the best of our ability, based on our current knowledge and resources at the time. We must avoid discredited techniques. Also, we should acknowledge that there is potential for harm and do our best to mitigate that harm.
We may have been taught a set of ideas in university by lecturers we trusted. But science and knowledge are contextual and subject to constant change. We must commit to lifelong learning combined with an open and curious therapy stance.
When we follow these ethical practices, the therapy interventions we offer will be much more likely to lead to the best possible outcomes for our clients, for each of us as individual clinicians, and for us as a therapy community.
Read Part 1 of this article here.