Yesterday I commented on a UKCP misconduct hearing in which a client was left “crying daily and not sleeping” following a therapy exercise which involved being held. The therapist involved was found to have committed misconduct (though wasn’t sanctioned).
This caused me to ponder a question: can psychological therapies be described as having side effects? By this I don’t necessarily mean misconduct cases of the kind I’ve highlighted regularly on this blog. Can therapists who are not regarded as committing some form of unethical practice inadvertently and unintentionally cause harm?
It’s an under-researched area, though this discussion thread mentions quite a few papers on the topic. Trauma therapies are one particular field that springs to mind. There’s been a strong vogue for “psychological debriefings” following major disasters. Aid agencies, entirely well-meaningly, have flown out teams of workers to offer the disaster victims a one-off session of talking therapy, in the belief that this will aid processing the psychological trauma, and reduce the risk of full-blown PTSD. Given how widespread this is, it’s striking how little evidence there is for its effectiveness. Indeed some researchers have suggested that it can actually deepen rather than process the trauma, making PTSD more likely rather than less.
Perhaps part of the problem is the assumption, widespread in our society, that “it’s good to talk”. Something bad has happened, we must talk about it. For a quick musical interlude, this assumption was caustically satirised in the chorus line to Bloc Party’s State of Flux.
The “it’s good to talk” assumption (frequently coupled with another assumption, “something must be done”) is one I come across from time to time in my day job in Child and Adolescent Mental Health Services (CAMHS). I periodically have to fend off (again, entirely well-meaning) requests from parents, teachers, social workers and GPs insisting that a child should have therapy about an adverse event, when the child shows no inclination to want to talk about it. In some cases the child has shown every indication of just wanting to keep their head down and not think about it. At such instances I’ve had to politely but firmly insist that if this is their coping mechanism, then we need to respect that, at least for the time being. Why risk doing more harm than good by ripping apart a coping mechanism?
There’s another area where “it’s good to talk” is widely assumed: bereavement counselling. Again, the evidence base is controversial, with some suggesting that it can do more harm than good. I’m not suggesting that nobody benefits from bereavement counselling, but as with trauma, the assumption that it will automatically be helpful can be simply wrong. I speak from a degree of personal experience on this. I’ve lost both parents, and in both cases I processed the loss without attending any counselling at all. this shouldn’t be too surprising: death is simply a part of life, and people recover from bereavement all the time without therapy. I certainly felt more distressed than helped by the number of people who kept telling me, “Seriously, you need to talk about it.”
Another potential adverse effect of therapy can be when it creates the impression that Something Has Been Done when in fact Something Else Needs To Be Done. I was recently on a child protection course attended by professionals from various agencies, and wound up triggering a huge argument. We were discussing a fictional scenario in which a small child was found to be unfed, in a house that was unheated, with a mother who was drinking heavily. At this point a counsellor from a voluntary sector agency piped up and said, “We need to be looking after the child’s emotional wellbeing. They should be sent for counselling.” At this point I replied, “You need to be looking after the basics first. There’s absolutely no point in sending a half-starving child to counselling.”
The response was uproar. The counsellor told me, “I disagree. We regularly support people children whose basic needs aren’t being met by the parents”, with several people lining up to support her view.
I found that quite a horrifying experience, and it left me worried not only about the counsellor’s practice (“So, you’re cold, you’re hungry and your Mum’s unconscious in her own vomit. How does that make you feel?”) but also about what assumptions would be created by such a child being sent to therapy – not just by the counsellor but by other professionals involved in the case. “We’ve solved the problem! The child’s been sent to a therapist!” In such a scenario there could be social worker, teachers, GPs all congratulating themselves that Something Has Been Done and The Child Has Been Helped because a therapy referral has been made. I’m sure they’ll all feel great about it right up to the point when the child is found battered to death.
I may have wandered slightly from the original point here, that therapy can cause harm even where there is no misconduct. Whereas trauma therapists and bereavement counsellors might be excused due to the paucity of evidence bases, the counsellor in the above anecdote ought to have had some basic awareness of Maslow’s hierarchy of needs, and her comments could raise potential concerns about the safety of her practice. I’m still forming my thoughts on this topic, so would appreciate the feedback of others, particularly where therapy has had an adverse effect that nobody could have predicted.