You cannot look up drug information on the Internet today without coming across at least one page about the negative side effects of taking the drug. In fact, such side effects are deemed so important, their publication alongside the benefits of a drug are strictly regulated by the U.S. Food and Drug Administration (FDA). But the FDA requires no such warnings connected to other mental health treatments, including the use of psychotherapy.
How could psychotherapy ever be harmful?
That’s a good question, and one explored in three articles in the January issue of American Psychologist. The one I’ll focus on is the one by David Barlow (2010). David Barlow is a well-respected psychologist and researcher, with a long career made on studies examining the positive impact of cognitive behavioral techniques for a variety of serious mental health concerns like anxiety and panic disorder.
In the article, Barlow notes how now that psychotherapy has become an accepted and effective treatment option within the health care community, researchers need to do a better job of describing and examining the negative side effects of psychotherapy. We can no longer make the claim that psychotherapy can have no negative side effects, even when wielded by an ethical and experienced therapist.
One of the best examples of this that Barlow noted is the research into something called “critical incident stress debriefing” (CISD). This is a therapeutic technique meant to help people immediately after experiencing a trauma in their lives (such as a natural disaster or car accident). The common wisdom is that counseling immediately after a trauma is likely to be beneficial to the victims.
But what the research has found is that in groups of people who have been treated with CISD actually experience greater and more severe symptoms when later measured. This made little sense to researchers — how could people who’ve actually been given a psychological intervention then later go on to experience even worse symptoms?
A more refined analysis found that it was actually only people who had high scores on a measure of the impact of the traumatic event who fared much worse later on after the psychological intervention. People with low scores on the same measure did just fine with the intervention. Barlow’s point is that we often can’t see the important variables that could have a negative impact in treatment until we take apart the data and examine it more closely.
Another example Barlow noted of negative side effects for a therapeutic technique is the use of breathing retraining and relaxation procedures during exposure-based procedures for individuals with panic disorder with agoraphobia. People who were taught these techniques actually fared worse off in coping with their panic than those who were not taught to use them. In other words, just because a therapeutic technique is useful in one situation — outside of exposure procedures, for instance, to help reduce anxiety or tension — doesn’t mean it might not be harmful in other situations.
These are often difficult cases to find, because just like psychiatric medications’ side effects, not everyone will experience them in every setting. There are specific traits or symptoms that may preclude the use of specific therapeutic techniques. To say nothing of normally-beneficial therapeutic techniques used inappropriately by inexperienced or poorly trained therapists.
Psychotherapy is a powerful treatment for mental health concerns. It’s time that more focus be given not only to its beneficial effects, but also to better understand when certain techniques are best not used and could, in fact, be harmful.
Reference:
Barlow, D.H. (2010). Negative effects from psychological treatments. American Psychologist, 65, 13-19.
28 comments
How is teaching breathing/relaxation techniques a bad thing during exposure therapy? A key component to exposure is relieving the panic/anxiety during or directly following the exposure. How are you going to do that without relaxation techniques…?
Because Exposure Therapy itself is a horribly misguided form of psychiatric malpractice that should be forbidden by law. To the author, thank you for giving me some hope….At last, a shrink who knows the limits of shrinking…. (When the patients welfare disappears in the sanctimonious dimentia of the therapist ie Foa!
When I had to be arrested by state troopers for the safety of myself and others because of being subjedted to “Exposure Therapy at a VA clinic it was wise doctors who
For more on the point you’re making, see
“The mental health crisis that wasn’t: how the trauma industry exploited 9/11”
by the noted social critique Christina Hoff Sommers,in REASON magazine from the summer of 2005
You can read the whole article at:
http://findarticles.com/p/articles/mi_m1568/is_4_37/ai_n15998616/
This is to everyone…as I couldn’t find the button to comment. Therapy helps nobody. Even if you think it helped, bullshit degrees in social work, psychology are based on lies, opinions and nothing tangible. We think that going to person with a degee in these things qualifies them to guide us, tell us what to do is beneficial. It never is. And whatever arguments that you have to so called prove your point, is mute to me. How do we determine truth in this existence and determine help? A lot of people who thought they were helped or fixed by their many years or time with a therapist discovered down the road it never helped at all. Therapists are wolves in sheep’s clothing. If you are human, you can’t help others unless you are absolutely perfect. No human is. And these therapists come to you with the problems of wrecking their own families, can’t solve their own problems with their degree… but claim they can solve your problems or “help†you. Think about that, when you seek help from a so called qualified person, doctor or whatnot. There is negligence in every therapeutic profession is the millions. Trust your doctor knows what he’s doing? You could be his first of many of his or hers mistakes.
Your article is timely and deserves further exploration.The field of psychotherapy/psychiatry itself would be well served by engaging in honest self-reflection, evaluation and efficacy.FOR THE SAKE OF THE CLIENTS. Rather than the common tendency to avoid the work necessary to identify, confront, and modify those habitual beliefs in “cookie cutter counseling”.
*** long post follows …
Quote from above article… “To say nothing of normally-beneficial therapeutic techniques used inappropriately by inexperienced or poorly trained therapists.”…
Poor training or inexperience seems less dangerous than a field which attributes to it’s practitioners a higher than deserved level of psychological health by virtue of the training. Example: on the far end of spectrum; The mentally unstable military psychiatrist, who continued to be rewarded and advanced in his field, despite the obvious warning signs. By virtue of his position, status,(deserved or otherwise), and the tacit agreement/denial/cognitive distortions by his peers. Directly contributing to the horrific outcome. The lone voice of objection to this blind pedagogic approval, was unfortunately silenced vigorously or ignored, and later blamed for the outcome.
It was not simply due to inexperience or poor training alone which enabled this to take place. The climate which he trained in,deliberately and repeatedly minimized and ignored the red flags. I suspect in favor of upholding the idealized roles of the peers which seem to offer little value in applying the training to themselves with rigor first. Perhaps in order to spare the fragile ego of the trainee. And by extension those who could have taken a stand but chose not to. By sparing him from facing his own wounds, he went on to do much worse to others. This is endemic in the field in lesser ways every day.
In my personal experience, there is no end to the ugly distortions, mind- bending, games and abuses from these tendencies in the therapeutic community. There very few courageous voices to speak up about the unhealthy behaviors commonly practiced. Alice Miller being one exception who comes to mind among others more recent.
There is big money in training/educating psychotherapists. the training methods generally agreed upon, seem to guarantee that there are many out there doing harm in the name of “healing”. The universities seem unable or unwilling to weed out those who are less than healthy themselves, in favor of pay to play the role. Paying large sums of money to become a healer,(especially favored among those whose BA has nothing to do with psychotherapy), get their MA in their new field, in an assembly line fashion. Most can find a way to pass standard testing process. Seems like a very poor business model, lacking effective quality control. Toyota certainly pales in comparison! The resulting end product of these institutions which seem to lack enough vigorous oversight or responsibility justifiably expected for such powerful “medicine”. Unfortunately there is no recall mechanism for the consumer’s benefit/protection. And very little discussion which would be helpful/educational is put forward.
The result is often a healing profession which ends up offering substantially less healing and more than it’s share of harm. If psychotherapy had an effective screening, evaluation and quality effectiveness testing program in place, similar to what the drug companies must go through to market medicines, there might be less mistrust and disapproval bias and resistance in general. We test everything offered to the public, to the utmost, except that which potentially effects our very souls. How crazy is that?!! How many “car wrecks from inappropriate therapy have we all seen”? Just because the injuries are mostly invisible, does not make the any less life threatening.
The negative reputation among practitioners in all therapy fields is well deserved. There are wonderful exceptions of course. For both the money driven pharmaceutical industry and the therapeutic industry. Each can be toxic in their own way. It is much more challenging to prove harm when it is done to the mind and soul of a client. And very little recourse is available for the one who carries this awareness virtually alone.
Due to the minimum avenues for effectively addressing the problems.The willing blindness benefits only no one in the end. An obviously repeating pattern which seems to be for the most part, irresponsibly ignored by the peers and teaching institutions, themselves.
I spent years of intense study to learn as much as possible about what was ethical, skillful and helpful, and learned to identify the opposite qualities with courage and conviction. Years of work to counteract, protect, and correct the toxic, distorted kinds of “help” I had received from these liscenced ‘professionals’. should not have been necessary if the work had been done by those who gave them validity.
My curiosity is to why there is so little information out there regarding how to protect oneself from toxic/unhealthy therapist? Why is there so little written of the warning signs, red-flags, or questionable therapeutic interventions? Not every medicine is expected to benefit every patient the same. Medications have clear warnings and contraindications. Why are most warnings and education lacking in this field of medicine? Therapists would like to be taken seriously as a healing science. Yet the collective will seems lacking when it comes to being openly challenged as to whether it truly benefits clients based on follow-up and feed back. (ie. rigorous study as any science deserves).
Why are clients generally not expected to have credibility when it comes to evaluating their therapists and effectiveness of the modalities used? This seems to be a sign of archaic, patriarchal, backward thinking, for our modern world. [Similar to the resistance it took for the profession to address the harmful realities of sexual abuse].
Where are the verifiable measurements, including client feedback, validating the highest levels of excellence/effectiveness within the various schools of psychotherapy?
There is much written on what is wrong with the patient, and how to “help” them become healthier, more aware, balanced, etc… In my view there is very little professional support for honest self evaluation, investigation of ethical issues ,quality of care, and self regulation within the field itself. The expectation seems to be that the ‘fox guarding the hen house’ is capable and willing to self regulate. We saw what that expectation did for our trusted banking industry recently!
I have noticed the field has become a haven for highly functioning narcissists, whose tendencies embrace and empower in each other, the very traits they claim moderate in their clients. As in the previous example of the military psychiatrist, the unfortunate tendency is to give tacit or direct approval toward self-aggrandizement and an idealized identity/role. Support and approval for this pattern, along with habitually using others misfortunes to perpetuate their own issues, is all too common.
Yes, I recognize have my own cynical side coming through here. yet these questions are valid and I hope to read your thoughts on how they might be answered/resolved.
Life could be simpler. But only if I could force myself go along indefinitely with the “Emperors new clothes”!
Regards, Annapurna
My observation is that therapists participate in and amplify abusive dynamics. Therapists have tricks to get you to trust them when they are not always worthy of trust. It seems like it would be better to have a model where you gradually increased trust over time after the therapist earned it. They often fake being non-judgmental but reveal later that they are through their actions. I’m not sure that the health of the therapist is the most important thing. Other people I know that have experienced depression understand it better than those that have lived charmed lives. It seems that it is important to reconsider the scope of a therapists abilities.
Thanks for your post Annapurna. I am one of those people who do not have an undergraduate in psychotherapy, but is doing a Masters in it. In my country, there is no undergraduate in psychotherapy. There is one in psychology, but as I didn’t want to spend three years becoming a master statistician, that was not the route I followed.
I just wanted to say that not all of those of us who are going in at Masters level are unfit to be training. I have done my personal work for many years, and continue to do so. I don’t agree that I will be a poor therapist because I do not have an undergraduate degree in psychotherapy. I spend a lot of time reading about the adverse effects of therapy and client’s dissatisfaction in my own time, because understanding it is, as you say, a crucial part of the process.
I have met some very disturbing “experienced” therapists who seem to have little insight into the way they are transferring their own darkness to their clients. The more I train, the more I see that personal transparency is crucial to being non-harming and effective. The feedback that I receive from others, both loved ones and fellow students is my guide to how I am being in the world.
I really appreciate your post, because it speaks to my concerns about not being a harmful therapist, so clearly.
Dru said:
‘How is teaching breathing/relaxation techniques a bad thing during exposure therapy? A key component to exposure is relieving the panic/anxiety during or directly following the exposure. How are you going to do that without relaxation techniques…?’
Well although relaxation and breathing exercises may have a role BEFORE and AFTER exposures, if they are used during exposures they become a form of subtle (or perhaps not so subtle) avoidance to prevent feeling the full physical arousal associated with an anxiety or panic attack. In this case they simply help keep the ‘fear of fear’ cycle going.
I feel like the danger is more in the inappropriate fit of therapist and technique with client and problem(s). For example, David Barlow is a huge advocate of a technique called “flooding.” Basically, its about making the anxious person as anxious as possible so that they learn not to fear the anxiety and to accept it. I’ve tried it, and I not only didn’t get over my fear, I actually got traumatized by it and developed some PTSD symptoms. (I was doing this on my own). My therapist doesn’t support “flooding” and claims it tends to be traumatizing or at least can be.
If you look at psychotherapy treatment articles, you will find that certain clients far worse after the psychotherapy or don’t improve (waste of money and/or time). In my own personal experience, I left many of my therapy sessions feeling very upset and sometimes self-destructive. My therapist sometimes said or did things that messed me up. And my therapist is very experienced and skilled. She just needed to learn how to work with me. But I still think that over the long run, therapy was beneficial.
I don’t think you could really have “warnings” or treatment success rates though because it’s too individual.
I agree with Annapurna’s well-stated thoughtful post. The harm is built in to the very foundation of client-therapist relationships: paternalism, idealization, the illusion of rescue, dismissal of client feedback in the guise of “interpretation,” pathologizing, regression, dependency, victimhood, and encouragement of a narcissistic, negative worldview. And this from “well respected” therapists. When will psychotherapy examine itself?
The profession rarely seems to seek feedback from clients. “Unhappy” clients usually are explained away, just as in an dysfunctional family.
Missbella writes, The harm is built in to the very foundation of client-therapist relationships: paternalism, idealization, the illusion of rescue, dismissal of client feedback in the guise of “interpretation,†pathologizing, regression, dependency, victimhood, and encouragement of a narcissistic, negative worldview. And this from “well respected†therapists. When will psychotherapy examine itself?”
Missbella, I agree that the issues you mentioned are quite prevalent, however I wouldn’t say it’s a universal truth. It took multiple tries but I finally did find a therapist who was collaborative and not paternalistic, who focused on wellness as opposed to pathology, and she was emotionally stable which was definitely a plus. I worked with her until I addressed the things I needed to and graduated from therapy. THe question everyone in therapy should ask themselves is, Am I improving with their treatment? If the answer is no, then maybe it’s time to re-examine the treatment.
It’s unfortunate that there are so many screwball mental health professionals out there.
So, I’m mentally “unstable” now. I’ve recognized and accepted that “terrorfyimg” fact. My problem is that I cannot accept loss of loved ones. (I believe the only reason I’m still alive is because I’ve never lost a loved one). I was put on effexor XR over 2 years ago when my ex-wife and I divorced. I took myself off the medication when I was no longer depressed. The only thing which let me from killing myself or going mentally insane from sever depression was that I had hope that I would eventually meet someone else, which I did. I haven’t told my new wife how I am. The reason why is I fear she’d leave me, which would trigger severe depression again, which would force me to get on medication until I’m stable enough to meet somebody else. I’m living a very dangerous and unstable life. I’m fine as long as my loved ones are alive and I have somebody in my life. With all of this said, I have my first psychotherapy appointment scheduled in 2 days which gives me hope that I can one day be rid of this fear of loss that I have and truly begin to live my life. I’m 33 years old. After researching medication and therapy on the internet, it worries me even more. So my question is, are people like mysllf simply doomed to be another suicide statistic? Or could I hopefully live a happyand long life free of fearing things which I cannot control? Any advice is much appreciated. I’m sick of worrying constantly and would finally like to just start living my life the way life was meant to be lived.
I have had the worst times with therapists, as well. I agree with Annapurna – the schools do NOTHING to see whether their students can truly be decent therapists. It is a haven for people who want to ‘order’ others re: how to behave, what to believe. For many therapists, they may as well be in a cult – as the leader. Narcissists LOVE this profession.
Also, there is NO ONE in that therapy room but the therapist and ME. Tell me one profession where there are NO witnesses, ever??
They should be forced to have others ‘listen in ‘ on their sessions, at various times. THEN they might not spend their time telling you all THEIR problems; ordering you re: what you MUST do with your life; LECTURE you re: how they hate men (one female therapist did this to me); etc., etc. They might ACTUALLY treat you, like a decent therapist should.
I want to start a movement where consumers of therapy have to begin ‘consumer information’ packets when they begin their first therapy session. AND both have to sign – consumer AND therapist.
Hi concerned,
I’m so sorry you feel anxious about your life. I was diagnosed bipolar many years ago. I split up with my husband eight years ago although we’re still good friends. When my mother died in 2013 I went through a long period of depression and instability. Fortunately I found a therapist who could help me. I really hope your therapist can help you. You’re still very young and if you’re determined I’m sure you can find the help you need. The very best of luck.
Dear Sir, while agreeing to the fact that psychotherapy can have side effects, i beg to differ that the stated facts in the article are more of contraindications than side effects.
Good point. However, folks who engage in a treatment that are contraindicated may experience serious harmful effects. How often are thorough evaluations done before treatment begins to assess contraindications and indications if the vast majority of clinicians think therapy is only very helpful or less helpful. Even when thorough assessments are done, outcomes of treatments show that even folks where a treatment is expected to be helpful can actually be really harmful. Despite this, how often are clients really informed of this potential when being told they should start therapy ? Therapy is expensive, time-consuming, and draining, and while it may be helpful for some people in particular ways, it can also be really damaging to others. This topic is not talked about nearly enough.
14 years ago I was foolish enough to believe that mental health treatment was automatically a good thing. I had a great life but I was suffering from depression. The therapist advised me to begin taking antidepressants. Even though she thought that I might be Bipolar she made no mention of possible side effects or the necessity of a mood stabilizer. When I asked how often I should be coming in for treatment I was told to only come in when I felt like it because she didn’t need the business. The antidepressants started triggering severe Hypomanic episodes. Unfortunately neither the therapist nor the general practitioner recognized what was happening and I began a 12 year long medication induced nightmare. Prior to my treatment I had been very stable and successful. I think about how good my life was before all of this happened and can’t believe that I can possibly be were I am now. It has been almost a year since I discontinued the medication. I can’t begin to explain how horrifying it is to feel like yourself for the first time in over a decade only to realize that everything that was ever important to you has been destroyed. I caused so much pain and suffering to those around me during that time that I don’t know if I will ever be able to forgive myself. Now that I have learned about the effects of these medications I have managed to piece together what happened over the last 12 years. I wish I had known then what I know now. It could have so easily been avoided. My biggest mistake was trusting professionals that were too arrogant to acknowledge their limitations.
Erte, I am so sorry (this is a complete understatement) that you, or should I say, yet another person has to go through this radical derailing of their life for no good reason. *If* you would find it helpful to read articles about medication-induced suicidality, hypomania etc, the website madinamerica.com is an excellent resource where you will find others who have been through a similar experience and are making it their life’s work to notify others of these problems that health ‘professionals’ do not know about.
I wholeheartedly agree with many of the concerns expressed here about the harmful nature of psychotherapy. I would especially like to thank Annapurna for her thoughtful and much-needed exploration.
Therapy can be an identity-changing, dehumanizing, shaming, exploitative experience that causes far more harm than good. Therapists are trained to seek out pain and problems, and by subtle (perhaps not consciously intentional) manipulations often create or exacerbate the very problems they purport to try to solve often by twisting memories (especially for clients who are particularly vulnerable or susceptible to influence by “authority”). While this is a profitable business model for therapists because they are able to create dependencies and create the problems that they then request payments to try to “solve,” it is harmful to consumers.
When we try to relegate humane support to paid workers (such as the psychotherapy industrial complex with labels and incentive structures that conflict with lasting health and flourishing), we chip away at the humanity of us all. We are all in this together, and we can do better.
Good discussion. Every field of endeavor does some damage along with the good–it’s inevitable because humans are at work and we’re far from perfect. It’s about time that the field of psychotherapy admits this simple fact about itself as well.
Yes, psychotherapists are notorious for being blind to their own weaknesses. But the problems for psychotherapy run deeper than this. For starters, the practice has not passed the valid replicable randomized controlled trials with active control groups that properly control for expectations that are required for it to be considered legitimate “healthcare†or “treatment.†To the extent that practitioners attempt to present it as such, they are engaging in dishonest quackery. The harm that is caused is not justified by any counterbalancing validated good; anecdotal “evidence” does not cut it in the face of people getting hurt. Continuing the practice under such terms is unethical.
This simply isn’t true. The research is full of the equivalent of placebo-control, randomized trials for psychotherapy. You can’t do a traditional placebo like a pill (since there isn’t one for psychotherapy), so researchers have used other sham treatments or a wait-list control group to demonstrate its effectiveness.
But yes, we have many decades’ worth of such research showing that psychotherapy can be as effective or more effective than virtually any psychiatric medication, for virtually any mental disorder.
The key here is valid, properly designed, properly controlled, replicable research. What you have in clinical psychology is decades worth of “research” that is plagued by so many shady data practices, e.g., manipulating statistics to generate false positives, hiding data that didn’t show the desired outcome, the file-drawer effect, confirmation bias, allegiance effects, failure to use active controls that control for expectations, etc., that it amounts to virtually nothing. Plus when you take several small underpowered invalid studies and combine them in a meta-analysis, you just compound the problem.
And by the way, you *can* compare psychotherapy to a placebo treatment. In a very recent study when psychotherapy was compared to antidepressants and placebos, it was not shown to be significantly better than a placebo. In another very recent study (current decade) when psychotherapy was compared to active intervention control groups, there was no significant difference between it and alternative interventions such as exercise, bibliotherapy, and sham acupuncture.
“But yes, we have many decades’ worth of such research showing that psychotherapy can be as effective or more effective than virtually any psychiatric medication, for virtually any mental disorder”.
These sweeping statements always annoy me. First, you need to define by what you mean by ‘psychotherapy’. If you are referring to an experience in which a highly motivated, driven client is willing to buy into a sham process that contains sufficient ‘sciencey’ sounding terminology that fits with a belief and expectation (This is the placebo mechanism) that to partake an active role within the sham process will lead to an overall improvement in psychological well-being, then you are absolutely correct, ‘psychotherapy’ is incredibly effective.
However, if what you mean by ‘psychotherapy’ are the very particular qualities that are unique to a therapeutic approach such as transference/counter transference or interpretation in psychoanalysis, or the critical examination of dysfunctional thoughts that are a feature unique to a CBT approach, then no, your statement that psychotherapy is more effective than virtually any psychiatric medication is bogus. In fact, the specific ingredients that underpin any psychotherapeutic approach have never shown any, or at best, very limited effectiveness.
So, please define by what you mean by ‘psychotherapy’. Can you ever call any treatment protocol a psychotherapy when the very specific features of that treatment protocol are largely redundant in aiding psychological recovery? And if you can no longer call it psychotherapy, then what is it?
For me it was less about harmful side effects, and more about harmful primary effects. The main therapy relationship I had was fundamentally dysfunctional and toxic and eventually subtly abusive. It reinforced prior patterns of disempowerment and weakness. It became the very thing from which I was trying to escape. The other therapists I talked to about this showed little interest in understanding or even acknowledging the damage done. Rather they wanted to talk me out of it. In my research since, I have seen the same attitude in the professional literature. The experience was humiliating and devastating, and will likely never be the same. My therapist, on the other hand, suffered no more consequences than having to hear the truth from me in a phone call, before cutting me off for good, and returning to her fantasy world where she can do no wrong.
Psycho therapy is just what it purports to be… therapy that has the potential to make a patient psychotic. Mercy Rogers, one of the first victims of Freud’s assault on America at the turn of the century, promptly killed herself after being subjected to psycho therapy. Unfortunately, there was no mercy for her. Only death.
What is so dangerous about psycho therapy?
Take a moment and ponder something frightening you experienced as a child. Then notice how your heart rate has risen, your breathing has quickened and your eyes have moistened.
Nature buries traumatic memories so that we can continue our lives. Psycho therapy uncovers those memories, amplifies and magnifies them a thousand times over, and then leaves the patient overwhelmed, out of control, and even psychotic. All while relieving them, or their insurance company, of large sums of money.
There is nothing more dangerous, more frightening, nor more soul destroying in this life than to experience a psychotic break accompanied by terrifying panic attacks that has been triggered by uncovering traumatic childhood memories.
This is PSYCHO THERAPY.
I’ve had good and bad experiences with therapy. I had a very good response to exposure therapy to treat a phobia. It worked great.
I had a really bad experience with a therapist who treated me for childhood sexual abuse by my dad. My dad convinced his (now) partner that I am a bad person and new partner was nasty to me from day one. The therapist spent a lot of time defending this new partner and her actions toward me. It felt really bad. The truth is that his new partner has been very cruel to me and my siblings (we’re all adults). I actually paid money to have some therapist defend new partner! New partner verbally attacked my sibling the first time she met him and told me how much she dislikes my sibling. New partner doesn’t even know us, and is just plain old mean. That therapist wasted my time and money and was not supportive. Therapy is hit or miss.
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