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Two Forms of Harmful Therapy

November 5, 2010

As a follow up to a recent discussion on an earlier blog posting it occurred to me that there really are two basic forms of harmful therapy, two basic ways in which therapy can go wrong and result in harm. One way has to do with the form of therapy chosen. The therapist uses a particular type of therapy that is harmful. The other way has to do with the therapist’s own personality and manner of relating to others. A therapist who has an agenda of power and control or who is so self-absorbed he or she is unable to really understand the client’s point of view can do great harm, regardless of what type of therapy is used. Of course it is also possible that both could exist in the practice of one therapist.

Much of the writing about bad therapy has centered around the latter and I think that this is where people are coming from who maintain that making sure your therapist is in therapy or in peer supervision will be helpful (although I still have to strongly question the evidence that therapy or peer supervision would change a therapist with such a problem/personality).  The main disagreement I have is generalizations that a therapist should necessarily be automatically dismissed just because they are not in personal therapy or peer supervision or even if a complaint has been filed. The fact is that given that a complaint can be filed by anyone for any reason, completely innocent therapists can be accused of all kinds of things. This is especially the case with therapists who are whistleblowers and file legitimate complaints against other therapists. The therapist complained against can easily retaliate and file a complaint against the therapist who complained about him/her. If we encourage therapy consumers to assume guilt by the mere fact a complaint has been filed, what will that do to any therapist’s willingness to blow the whistle on unethical colleagues? If guilt by the fact of a complaint is going to be assumed most therapists would decide to remain silent.

In the latter case, the therapist is said to be narcissistic or even sociopathic and this has a toxic effect on the therapeutic relationship and this would be the case, regardless of whether the therapist was using an otherwise helpful type of therapy [as an aside, I have to note that I think the term, narcissism has recently become the latest fad “diagnosis” and is over-used by some people to explain any type someone becomes upset with another person – that being said, I do acknowledge that there are certain people who do have such traits who can be toxic to others]. For example, behavioral approaches which have been shown to be very effective for a number of different types of problems could be deadly in the hands of a manipulative person who could use the techniques to control the other person rather than help them.  There may be some validity to screening out such a person as a therapist by asking if they are themselves in therapy or peer supervision, because such a person is not likely to be looking for help of that kind. However, that doesn’t mean that all therapists who are not in therapy or peer supervision are necessarily going to be bad therapists.

That being said, there is also the category of bad therapy where the therapist is a well-intentioned, empathic person who really cares about the client, but is using a method of therapy or therapeutic technique that does more harm than good or is ineffective. Asking if a person is in peer supervision would not screen out that sort of therapist because many such therapists who are true believers in a particular form of therapy may well be in peer supervision and very open to feedback and they may also themselves be in therapy. In such a case, the peer supervision might actually reinforce the entire group of therapists to continue using the harmful or ineffective therapy. The way to screen for that type of therapist is to ask the person what evidence he or she has that the therapy is effective and if you are giving nothing other than testimonials and anecdotes and is making big claims even though little to no high quality research exists, , that is a very bad sign.

Peer or other supervision is fine and very helpful when it is done in the context of an intervention that has actually been shown to help, an evidence-based therapy. In that case, it is very important to learn how to do such an intervention correctly and skillfully and getting feedback from others can be very helpful. If that is not the case, however, what we are left with is authority based practice and/or groupthink and this not something that will ultimately help the therapy consumer.

  1. You present some interesting critiques and insights…but what do you think would in fact, help and protect, the therapy consumer? What changes to the current “acceptable” practices would you make?

  2. I think that changes need to be made to the codes of ethics themselves and then enforced by the state boards. The main change I think needs to be made is that codes of ethics need to be much more clear about the need to present the client with accurate and up to date information on the actual research evidence that exists to support the therapies they are offering and if the therapies being offered lack evidence, the client needs to be informed of that along with information on any alternatives that exist that do have evidence to support them. If well documented reports of harm exist, from a particular practice that lacks solid research evidence, that practice should be banned entirely and anyone caught using such a practice should automatically and permanently lose their license.

  3. Monica, I so appreciate your vigilance and skepticism. So I’m writing this out of respect rather than provocation. I wish psych professionals would expand their thinking into other ways that therapy might harm.

    I experienced that therapy can be perfectly ethical, the practitioner perfectly respectful, yet therapy still a bad brew. I have to remove therapy from its theoretical picture frame and simply consider what happens there between human beings. Inevitably the power dynamic is always extreme–one person plays the role of the wounded one, the other as the authority and healer. I found no matter how the provider soothed and reassured, no matter how many assertiveness exercises, autonomy and agency are impossible within that dynamic.

    I also experienced therapy is a large distortion of my wounds and flaws. Life’s injuries and defects became a magnification and fixation, as if mine were apart from all the others of my species. I began to see myself in therapy-think a dissected, long-distance lens, that second-guessed everything I did, felt, and why I failed.

    I also found my relationship with therapists the equivalent to relating to a cad lover, warm and focused for those 50 minutes, though utterly withholding the other 167 hours a week. The therapists controlled the narrative and set the rules. The client inevitably is the imploring disciple.
    Then too, the intimacy of it was a performed simulation as opposed to the spontaneous, reciprocal real deal.

    Ultimately and unfortunately therapy exploited my fairy-tale need for transformation, relief from life’s inevitable sorrows, from the limitations of merely being human. Therapists led me into or allowed my unrealistic expectations. (Maybe you’d think them bad therapists for them.) I plunged in, complied, idolized, and finally emerged completely brainwashed and self-absorbed, but with no improvement coping in the real world. And yet time and experience has demonstrated that I’m perfectly capable of growth and change. It’s simply that therapy could not have accelerated this.

    So I posit that not everyone benefits from “ethical” therapy, and some well might be harmed. I don’t know where this leaves the conscientious practitioner. But I think both consumer and provider need increased awareness that therapy’s nearly inevitable paternalism simply isn’t good medicine for everyone.

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