1: Hvorfor bry seg om negative effekter i terapi?

Dette er første innlegg i en serie av mange. Seriens overordnede tema er negative effekter i og av psykologisk behandling. La oss starte.

Jeg husker fra psykologstudiet ved NTNU at vi lærte mye om hva som fungerer og hvordan vi bør gi pasientene våre best mulig terapi. Ulike terapimodeller, innfallsvinkler og teorier om psykisk helse ville hjelpe, ble vi fortalt. Vi fikk se video av de beste terapeutene. Samtidig snakket knapt nok ingen om at terapi kan gjøre vondt verre.

De siste 6 årene har jeg fordypet meg i nettopp dette, såkalte “negative effekter i terapi”. Det er i ferd med å bli en bok. Nå også denne bloggen. Hvorfor bryr jeg meg - og hvorfor bør du bry deg?

For det første handler det om pasientene som kommer til oss terapeuter for å få hjelp. De har rett til å få vite hvis det finnes en risiko ved behandlingen de får. I dag er jeg bekymret for at mange tar på seg skylden for at terapien ikke fungerer eller gjør dem verre: de tror det er dem selv det er noe galt med.

For det andre handler det om terapeutene som skal gi hjelp. Noen ganger nytter ikke terapi - uansett hvor varme, empatiske, flinke og erfarne vi er. I verste fall holder man disse forløpene hemmelige, strever i ensomhet og blir utbrent eller skamfull - der man i stedet kunne lært av feil, utviklet seg faglig og hatt et sunt forhold til at det noen ganger ikke nytter.

Det finnes flere argumenter for å ha fokus på negative effekter. Et slikt fokus kan hjelpe oss med å gjøre allerede god terapi enda bedre. Det er nemlig slik at god terapi ikke nødvendigvis er fri fra negativ elementer, og får man identifisert og eliminert disse vil dette løfte fagfeltet som helhet. I tillegg kan større bevissthet og kunnskap om temaet hjelpe oss å finne enkeltterapeuter som burde gjort noe annet enn å drive med terapi (La oss håpe det ikke er for mange av disse). Eller hva med de store økonomiske besparelsene ved å redusere omfanget av terapi som ikke nytter eller forverrer. Samfunnet kan spare hundrevis av millioner.

Argumentene er for mange til å redegjøre for de i et første innlegg. Du som leser vil miste interessen. I bunn og grunn handler denne bloggen - bokprosjektet, forskningen og foredragene - om noen grunnleggende verdier og prinsipper for hva helsevesenet vårt skal være. Om etikk; om å ikke skade og om gjennomsiktighet; at terapeuter og pasienter skal vite at det er en risiko involvert.

Denne bloggen har ikke en forutbestemt retning eller et overordnet mål. Den skal være min formidling av et tema jeg kan en del om. Noen ganger er utgangspunktet for ett innlegg noe som er dagsaktuelt (som denne saken om gestaltterapeut Erik Bisgaard), andre ganger en forskningsartikkel eller flere som jeg mener er interessante. Noen ganger blir innleggene mine klinikknære og kanskje til og med nyttig for terapeuter - andre ganger vil det være forbrukerstoff som pårørende eller pasienter kan ha interesse av å lese.

Why aren´t therapists talking about this?

This text was first published in Scott Millers blog.

Turns out, every year, for the last several years, and right around this time, I’ve done a post on the subject of deterioration in psychotherapy.  In June 2014, I was responding to yet another attention-grabbing story published in The Guardian, one of the U.K.’s largest daily newspapers. “Misjudged counselling and therapy can be harmful,” the headline boldly asserted, citing results from “a major new analysis of outcomes.” The article was long on warnings to the public, but short on details about the study.  In fact, there wasn’t anything about the size, scope, or design.  Emails to the researchers were never answered.  As of today, no results have appeared in print.

One year later, I was at it again—this time after seeing the biopic Love & Mercy, a film about the relationship between psychologist Eugene Landy and his famous client, Beach Boy Brian Wilson. In a word, it was disturbing.  The psychologist did “24-hour-a-day” therapy, as he termed it, living full time with the singer-songwriter, keeping Wilson isolated from family and friends, and on a steady dose of psychotropic drugs while simultaneously taking ownership of Wilson’s songs, and charging $430,000 in fees annually. Eventually, the State of California intervened, forcing the psychologist to surrender his license to practice.  As egregious as the behavior of this practitioner was, the problem of deterioration in psychotherapy goes beyond the field’s “bad apples.”

Do some people in therapy get worse? The answer is, most assuredly, “Yes.” Research dating back several decades puts the figure at about 10% (Lambert, 2010). Said another way, at termination, roughly one out of ten people are functioning more poorly than they were at the beginning of treatment. Despite claims to the contrary (e.g., Lilenfeld, 2007), no psychotherapy approach tested in a clinical trial has ever been shown to reliably lead to or increase the chances of deterioration. NONE. Scary stories about dangerous psychological treatments are limited to a handful of fringe therapies–approaches that have been never vetted scientifically and which all practitioners, but a few, avoid.

So, what is the chief cause of deterioration in treatment? Norwegian psychologist Jørgen A. Flor just completed a study on the subject. We’ve been corresponding for a number  of year as he worked on the project.  Given the limited information available, I was interested.

What he found may surprise you. Watch the video or click here to read his entire report (in Norwegian).  Be sure and leave a comment

Psychotherapy Works, But Not For Everyone

This text is part of a post published in Huffington Post written with professor Allen Frances.

First, do not harm. This is the famous Hippocratic oath well known in the world of medicine. In the world of psychotherapy, however, harms have not been subject to much interest.

Since Sigmund Freud and Joseph Breuer discovered that talking to people could cure bodily illness, researchers have asked questions about the effective components of psychotherapy. Is it the specific techniques? The healing powers of the therapist? The general effects of being understood, validated and listened to? All-important questions, but they fail to acknowledge the full picture.

There is no doubt that psychotherapy works for most of the mental disorders. If the interventions we use are potent enough to create positive change, it should not come as a surprise that they are potent enough to damage people as well. It is estimated that as many as 15 % of patients get worse following treatment.

Negative effects come in two major forms: 1) worsening of problems already present, such as hopelessness or depression; and 2) new problems might emerge, such as becoming dependent on the therapist, marriage issues, or reduced self-image.

Often the patient is blamed when therapy doesn’t work, labelled as “treatment-resistant” or “unable to profit from therapy”. This is sometimes true, but is the least fruitful approach for explaining negative outcome. Sometimes the therapy technique is dangerous. Recovered-Memory Techniques and Dissociative Identity Disorder-Oriented Psychotherapy should come with a warning sign.

And most important is the therapist. Some therapists are empathic and intuitive, ask for feedback, evaluate the therapy, and share the goal and process continuously with the patients. Others fall short on one or all of these critical dimensions. It may not be the technique that is harmful, but rather the wrongful use of it.

Lack of empathy, hostility or anger towards the patient is never to be accepted. Failing to understand the patient’s unique problem, not validating shameful feelings, or being unable to establish an alliance are other examples. Too much comforting or reassurance can promote dependency between therapist and patient, decreasing autonomy in the process. Lots of stuff goes wrong from time to time in all therapist offices, but research shows some therapists are significantly worse than others.

The English version of Hippocrates, Thomas Sydenham, realized 400 years ago that patients get worse by overtreatment. His cure? To do nothing, and let the natural healing process do its magic. The natural course of illness, with periods of both worsening and recovery, makes it incredibly difficult to determine the effects of psychotherapeutic interventions. It also suggests that sometimes illnesses heal by themselves.

Therapists typically fail to see deterioration before it happens. In one study, therapists were asked to spot patients who got worse. Out of 550, only one patient was correctly identified - 39 negative outcomes were missed. When using a statistical alarm system, however, 77 % of the deteriorating clients were identified beforehand.

Therapists need to ask patients for feedback and be self-critical about their own performance. The ethical responsibility for avoiding harm is shared across the field. Supervisors, psychotherapy researchers, colleagues, teachers and health officials all need to raise the awareness on the potential for negative outcomes. Harmful therapies should no longer be done. Harmful therapists need to be retrained or go into some other kind of work.