When it’s not good to talk: Adverse effects of psychological therapies

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.

 

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25 thoughts on “When it’s not good to talk: Adverse effects of psychological therapies

  1. Agree re. the last part of the post in relation to sending a child (or indeed anyone) who has basic needs that are unmet, for counselling. As a social worker in mental health in a particularly deprived area, I am constantly working with people who could by all accounts benefit from psychological input….at some point after their immediate and basci needs e.g. food, shelter and safety, are guaranteed. This is not always that case e.g. sometimes people are living in less than perfect situations but I still work them them therapeutically but on the whole I think it is ridiculous for professionals to foist our privilege and power on people by assuming counselling or some other form of “intervention” could be of real or meaningful benefit if a person’s basic needs aren’t being met first. That just seems like common sense 101 to me…?!

  2. There is an ” ego” thing going on here and I suspect is in many cases where therapy goes wrong. The therapists own ego creates a blind spot, which is where the unintentional harm can creep in. The word power springs to mind, as does wounded healer, who can only help to the point of their own healing and not beyond. A damaged healer is going to get off on power, no matter how much they may deny it.In my own case the complete shock of a bad ending from a slightly ,(or maybe not so slightly) unethical counsellor , who choose to lie to try to cover up mistakes, has left me reeling some 6 months later, hence I am writing this reply at nearly 2 in the morning.

  3. Hi Phil
    First off, I think you’re dead right that we can slip easily into the view that there is something privileged about psychotherapy/counselling. It can even feel as though not having/offering them is in some way negligent or insufficient, leaving parts of the mind harmfully untouched. When I worked on an inpatient ward as an Assistant Psych the other staff would speak as though someone having their “psychology” were the most central aspect of their treatment. I was sometimes left wondering if in fact the safe space, the care of friendly support workers and cleaners was more important. From the outside “psychology” acquires a magic aura; for the practitioner and the recipient it becomes clear it is simply a more or less helpful style of conversation. I am now getting my training in quite a psychodynamic milieu, so “depth”-talk surrounds me; people prefer an emphasis on “working through conflict” to one on changing one’s behaviour and experiencing changes downstream from that. So many of the metaphors of therapy promote this style of thinking. We talk about “resolving” things and we have a spatial “depth” metaphor of the mind that invites us to imagine things left in there rotting darkly. To be sure, these metaphors have something to them, I have had personal experience that attests to the feeling that a therapy can change something in one’s perspective that feels quite fundamental. However, they remain metaphors, and I am often impressed by how quite unsophisticated can be the things that make a real difference.

    As for the question in your second paragraph. Something about “side-effects” doesn’t seem quite right, simply because psychotherapy isn’t a pill, but that is a purely semantic argument. Psychotherapy is a human activity, and it can certainly have unintended consequences, just like all other complex social activities. To start, we can probably cause harm quite often. The Brigham-Young psychologist Michael Lambert is interested in how this can happen, and how, without symptom measures, we are often unable to spot it. Worsening of symptoms aside though, might there also be a broader form of harm associated with role we place clients in? A period of dependency upon the therapist, a focus on examining oneself as though you and your mind were the problem; these could all have quite detrimental impact on a person’s ability to cope and view themselves as having agency. This sort of role change is quite pernicious, and more subtle than medical side-effects (which, after all, strike most people as undesirable quite quickly). We should be quick to remember that side effects are highly undesirable and may negate the value of a pill. We are probably insufficiently quick to understand when the unintended consequences of therapy can do likewise.

  4. Good post Phil, thanks for writing. For me it’s relatively simple, yet complicated. Psych therapies can have adverse affects and part of this is because they cover an enormous range of ‘interventions’. In my own field, Attachment therapy is controversial, especially when it involves ‘holding’. This is basically, in my eyes restraint and forced intimacy. There used to be YouTube clips of it as it was popular in the states and some independent providers delivered this in the UK too. I think the clips are unavailable now. The PTSD interventions you mention are also well used, falsely in my opinion. This is where the genuine need for evidence based interventions comes to pass, despite my personal belief that this is very hard to do for what are essentially often uniquely tailored interventions. We must surely be able to at least do no harm.

    The concept of therapy for everything is a nonsense but it’s also where it is IMO essential to have an understanding of the person, not just the problem. I see many children for PTSD assessments. Some have had horrendous experiences but manage well. Others have experiences which many have without recourse and struggle greatly. It is, because we are, very individual.

    Life throws difficult things at us as you said, such as loss. We have to allow people to try to find their own way before bulldozing in and telling them they have had, for example, an abnormal grief reaction. Julian Barnes’s Levels of life highlights beautifully that there is no such thing as a normal grief reaction, it’s all down to the person experiencing it. I do think that this is where we need to work with people not the labels. Many don’t fit labels and struggle, many do fit and don’t. We need to be psychological about intervening.

    I agree with your point which caused such argument, Get the basics right first. However, there is another side to it. CAMHS are often seen as not getting involved until ‘things are more stable socially’ which is still at the root of much Health/social care divide problems. I will get involved if things are unstable (it’s what I should be doing I always think) but I will make a point of the primacy of social/physical needs in my formulation which forms the base of my intervention contract so as to ensure social care etc are fully on board and involved. Notably, much of this work is indirect (parents/carers/schools).

    Psychological interventions (much broader than therapy) can be very helpful to some people. It can be utterly useless too and for some it can make things worse. I think we have to get a lot better at working out what it is that we do that leads to these 3 very different outcomes.

  5. I have to agree that needs must be met first, and anyone who fails to understand the basics of Maslow is turning therapy into a magic wand rather than the process of self discovery it is. It seems to be related to the idea that “something must be done” as you mentioned and also the idea of the therapist as someone who “makes things better” This seems to me to be a huge failing in many practitioner. They see themselves as the active participant rather than the space creator (makes) and have a pre determined idea of what the client needs and wants (better)

    You know my story, for those who dont http://abusedbyatherapist.blogspot.co.uk/2014/04/jemimas-story.html there is another aspect to this though. Even without the recovered memory issues I strongly believe this was not the best time to have started counselling., and that any counsellor would have been better addressing basic issues such as my drug use (nothing particularly unusual in late 80s london) and other lifestyle issues. Basically I was a very young, immature 18, away from home for the first time and living in central london. A basic maslovian approach would have considered my security and safety before tackling the childhood sexual abuse.
    The desire to make me better was so strong though that the therapist leapt in to “do something” This ignore the fact that therapy is hard work, and the person needs the psychic resources, strength as well as their basic needs being met. This doesnt mean that counselling cannot work in less than ideal situations of course, it can be a part of a package of interventions, this seems to be a very useful approach when dealing with issues such as homelessness for example. However their must be an understanding that without the basics of food, security and shelter counselling could cause more harm than “good” in the short term.
    This is getting rather long, but I am reminded of another thing, a good friend has told the story before of going to see a counsellor after a particularly bad period in their life, they were depressed and had had suicidal thoughts. They were fortunate, on telling their story the therapist replied that frankly they would be worried by someone who wasn’t affected by the past 6 months.
    Such a common sense answer helped my friend enormously. They didnt need deep psychological interventions, just permission to not be the “big man”. Client centered should be a bedrock, not a handy catch phrase.

  6. Every relationship we enter brings with it ups and down, the therapeutic relationship is no different there (and shouldnt be) it is the inability of the therapist to work through any downs (or ups for that matter) with the client that causes the therapy to turn wounding/malignant/abusive. Most complaints about counsellors in particular are about endings gone wrong or boundaries violated – both of these things could be thought about (if the counsellor was able to ‘think’ at that time) but at the time it seems impossible. Most of the times this is not because the counsellor is evil and wants to hurt the client (although we do have the odd sadist that falls through the net) but because unconscious dynamics are at play that need to be thought about and understood (hence supervision)

    Being under state/government regulation will not change this phenomena. What needs to happen (and I talk about this on my blog) is help for both, the therapist and client because, believe me, the client will not be helped by the counsellor being struck off the registar or banned from practising. The client will still suffer (so will the counsellor) and if we really want what is best for the client, we wont let the government regulte our profession (God help us then) but provide adequate mediation and therapy/supervision to help the client especially move on.

    I have been a victim of therapy gone wrong and even though I had a meeting/hearing in fornt of the BACP and the counsellor was @punished@ it didnt help me one bit.

    We need to be careful and think really hard why we want to have counsellors punished vs have a resolution, help for the client. (and the counsellor, because if the counsellor doesnt get any help to understand what has gone wrong, s/he will be more likely to hurt another client, consciously or unconsciously.

  7. Interesting area…

    Next Wed (April 30th) we’ll be blogging about two new studies looking at the harms and side effects of psychotherapies. Do drop by and let us know what you think: http://www.thementalelf.net

    Cheers,
    André (The Mental Elf)

  8. Psychodynamic psychotherapy can be a very dangerous area as I have found out to my cost. In an institutional setting furthermore, the hazards can be more pernicious, not less since the therapist then sees their first loyalty to the group and not to the patient. Obviously this can work both ways, but nevertheless when there are conflicts of loyalty, the patient can end up seriously harmed. Some therapist groups behave as if they are some kind of special, privileged elite, and, as often happens in mental health (I can speak only of NHS trusts), the poor patient is not heard in any situation of disagreement/claims of abuse or neglect…as they are considered inferior/liars/deluded. There is a great deal of protection from various back-up organisations for therapists. Alas, the patient is left with very little back-up or protection when things go wrong. There also seems to me little real care or compassion for the patients – merely a show which is the result of following NICE or other guidelines. In my view psychotherapists are not sufficiently accountable, and there are far too many vulnerable patients ending up as serious casualties. (South Birmingham).

  9. Are you familiar with the Carol Felstead case? It may have already been discussed here, but I am reading this blog for the first time. A new coroners inquest has just been agreed, so this may be a topic that the mainstream media picks up again. Private Eye were involved in publicising the family’s concerns but I struggle to critically analyse this sort of case, as soon as SRA is mentioned all sorts of weirdness starts happening and I’m just not going down that rabbit hole (beyond the Broxtowe Files anyway, that seems legit).

  10. Jenna
    I am familiar with it and have contacted the father (I think) because I had an experience with the same ‘cult’ of therapists that could have shed more light. I had always held those the-rapists in high regard but I have seen the very dangerous side to them too. False memories, labelling of DID, making you another ‘project’, But the therapist who saw me did not know that I was a lot stronger and was able to protect myself and reach out. I could have easily been a victim of false memory created to have another ‘case’ under their belt to write books about. Im not saying all of the therapists who work there are like this,but the one I ‘worked’ with was very narcissistic. You can read more about her on my blog.
    Interesting that this case is being opened up now….my experience with these people might be f help to the family. Do you know how I can get in touch with them?

    • There is a website called Justice for Carol that I think is run by her family, I’m pretty sure it will have a contact button. I’m sorry but I don’t know how to link from my phone. It makes horrific reading, but it’s all horrific, isn’t it?

  11. Thank you Jenna

    To the author of this blog, could you provide me with your email address pls? I am in the middle of complaining to the *** about a therapist and I might have to make public what is happening within this process. Are there any journalists or papers who would be interested in the narcissistic power and control struggle within this profession and organisation? Where could I find them?

  12. Hi Phil, did you get some time to read up about this case?

  13. Now this does not surprise me. I have had personal dealings with Ms S and a colleague of hers in which I was told in the first (and last!) 3 sessions that I was part of a child prostitution ring, that I was abused as a child due to me not wearing a watch as an adult and so on (I wrote about it on my blog) When I challenged the therapist (who was under the wing of Ms S) she wrote me an email and told me she no longer wanted to work with me and finished with me in an email an attachment based therapist.
    Is this an open hearing? If it is I will fly to England especially to witness this.

  14. To be honest I am shell shocked by this news…. and why is it public? I wonder why it is public… does anyone know what this is about?

  15. Usually these meetings are held in private with only the both parties and their witnesses present.

  16. Is it a normal thing for the UKCP to hold hearings in public? I am sure the BPC holds all hearings in private if Im not mistaken.

  17. Thanks TO, Phil, will you cover this story/case? I would be very interested to read about it, specially as it involves Valerie Sinason…. who has a tight bond with the BBC by the way.

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