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.