Psychotherapy Works, But Not for Everyone

COMMENTARY

Treatments that work well for most don’t work well for all. And even effective treatments have side effects and complications. This is true of medication and surgery-and it is also true of psychotherapy.

Psychotherapy is a proven effective treatment and should be the first choice for mild to moderate psychiatric symptoms. Far too often people take unnecessary psychiatric medication for problems that would get better on their own or with psychotherapy.

[[{"type":"media","view_mode":"media_crop","fid":"32074","attributes":{"alt":"Psychotherapy","class":"media-image","id":"media_crop_996475010840","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"3392","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","title":" ","typeof":"foaf:Image"}}]]But sometimes psychotherapy creates its own set of problems. Like any effective treatment, it must be implemented well and applied judiciously for proper indications.

Jorgen Flor is a student in psychology doing his master’s at the Norwegian University of Science and Technology, on the topic of negative outcomes in psychotherapy. Mr Flor writes:

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, labeled 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.¹

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.

Thanks, Jorgen. The clearest findings from the psychotherapy research literature are that different techniques of therapy are about equally effective and that the nonspecific aspects of therapy are much more important than specific technique.

The best predictor of outcome is a good relationship between therapist and patient. A therapist who is great for one patient may be terrible for another. It is difficult to predict the success of match-ups in advance, but a switch should be considered if they haven’t hit it off well by the third session.

But we should keep things in proportion. Medications are way overused. Psychotherapy is way underused. Drug complications and overdoses are a serious public health problem. Psychotherapy complications are much less common. And much less severe. It would be a better world were there more therapy, less drugs.

Disclosures:

Note to readers: As with all blogs on this site, the opinions expressed in this commentary are solely those of the author. Comments not followed by full names and academic titles will either be removed or heavily monitored. -The Editors

References:

1. Hannan C, Lambert MJ, Harmon C, et al. A lab test and algorithms for identifying clients at risk for treatment failure. J Clin Psychology. 2005;61:155-163.