|Clinician's Digest - Page 2|
Does therapy occasionally cause more harm than good? This isn't a question many therapists or researchers like to think about, despite the fact that between 5 and 10 percent of the time, clients deteriorate during therapy. When researchers and therapists examine treatments or reflect upon how therapy is going, they usually attribute any null or negative effects to intractable symptoms, a deteriorating disorder, or unfortunate circumstances outside the office. Even when the worst things happen to clients—homicide, suicide, psychiatric hospitalization—we seldom consider that therapy itself may have had some harmful effect. That notion usually arises only when a therapist uses some untested and controversial therapy or grievously violates boundaries.
But writing in one of three articles in the January issue of American Psychologist addressing the possibility that therapy sometimes causes problems, Sona Dimidjian of the University of Colorado and Steven Hollon of Vanderbilt University contend, "If psychotherapy is powerful enough to do good, it may be powerful enough to do harm." They describe various ways in which treatment can backfire. It may make the problem worse or cause harm in domains that aren't the focus of therapy. A therapist may help release a client's anger in session and the client may then cause a road-rage accident. A couple may be in therapy to work on communication issues, and then one of them may decide to leave the relationship. Harvard psychiatrist Richard Schwartz has wondered whether some people become so dependent upon therapists' support that their social network deteriorates. Even empirically supported treatments may occasionally cause harm. For instance, exposure therapy makes some people's anxiety worse, and some depressed people deteriorate with certain treatments.
Researchers are partly to blame for the underemphasis on harmful therapy, says Boston University psychologist David Barlow in a second article. He notes the irony that 40 years of increasing refinement of psychotherapy research has predominantly focused on finding positive results, best practices, and empirically supported treatments, with a concomitant underemphasis on harmful effects.
In an article by five therapists led by Louis Castonguay and James Boswell of Pennsylvania State University, the authors suggest that instead of focusing primarily on teaching empirically supported treatments and clinical techniques, training programs should also stress ways in which therapy can do damage. Knowing what's empirically supported is important, but so is informing students that continuing to use a specific technique when it doesn't work causes harm; clients can feel worse about themselves and become discouraged about seeking further help. A study led by Derek Hatfield and Lynn McCullough, reported in the January 2010 issue of Clinical Psychology & Psychotherapy, corroborates the dangers that arise when therapists haven't been alerted to this possibility. It matched self-assessments of how they were doing in each therapy session from 70 clients with the therapists' notes and found that therapists hadn't noticed when their clients had been deteriorating.
Bringing into the open the issue of harmful therapy reflects one of the bedrock principles of therapy: ignoring a problem doesn't make it go away, and may even make it worse.