The Alleged Risks of Psychotherapy

[David Baxter PhD]

The Alleged Risks of Psychotherapies
Wednesday, June 20, 2007

A column in the most recent edition of Newsweek addresses a sometimes-controversial topic in mental health circles: negative outcomes of psychotherapy. The subject is tackled by science writer Sharon Begley, and throughout her piece she raises many legitimate concerns about the potential for risk and even harm during therapy. Begley points to the fact that the FDA requires warning labels for known side-effects of drugs, but no similar warnings have ever been required of psychotherapeutic techniques. While Begley takes an extreme, cynical stance toward the value of therapy, playing up potential risks for individual therapies and de-emphasizing the all-around benefits of treatment, her article does point to a larger question about the use of therapeutic techniques that haven't been thoroughly vetted and the responsibility of therapists to communicate any potential negative effects to their clients.

In her column, Begley refers often to Scott Lilienfeld, a professor of psychology at Emory University, who has been at the front of a push to more closely examine the negative impact of therapy, which is referred to technically as "deterioration effects". In his work Pseudoscience, Nonscience, and Nonsense in Clinical Psychology, Lilienfeld has pulled together a large number of studies that contain evidence of deterioration effects. He goes beyond just debunking the curative power of dubious methods like eye movement desensitization and reprocessing to claim that many patients are actually harmed by their treatments.

Lilienfeld's work focuses on the dangers of pseudo-scientific techniques with no regulation, but others have found evidence of negative effects in more well grounded treatments. Rudolf Moos, a researcher from Stanford University, found in a May 2005 study that 7-15% of participants in substance abuse therapy programs exited worse-off than they began.

Despite evidence of some negative outcomes, there is no queston that psychotherapies have a net positive effect. For confirmation of this, one has only to look at the extensive list that the APA compiled of studies that proved the efficacy of psychotherapy. Just a small sample: Mary Smith and Gene Glass examined 375 evaluations of psychotherapy to show that 75% of patients were better off than untreated individuals. An even more precise study was later done to break down the amount of benefit that patients received at different stages of therapy. It not only confirmed the earlier finding by showing that 75% of patients were improved after 26 sessions, but it also revealed that 50% were improved after 8 sessions. This sort of rigorously quantified study is very healthy for psychiatry. There are admittedly some obstacles in the way of scientific comparison because of confidentiality concerns. In addtion, therapists are increasingly moving away from a strict reliance on Freud, Jung or Adler to an ecclectic mix of methods, which is harder to evaluate. Even so, the many studies complied by the APA show that all of these obstacles can be overcome.

Evidence-based treatment has been tightening up many of the psychiatric fields where positive therapeutic claims were once accepted. One treatment method particularly suited for evidence based outcomes is Cognitive Behavioral Therapy (CBT), which finds a solid middle ground between the strict claim of behaviourism that internal mental states are irrelavent and the hard-to-test claims of methods that utilize psychoanalytic techniques. Even though cognitive therapy can be successfully evaluated, most mental health practitioners do not have their patients fill out extensive psychological tests before, during and after treatment. There is no incentive for this type of data gathering by clinicians because insurance plans will not pay for routine test administration or the scoring of such tests.

Of all the areas that receive attention for deterioration effects, grief counseling is among the most hotly debated. At the center of this storm is a meta-analysis presented by R.A. Neimeyer in 2000, which concluded that 38% of the recipients of grief counseling would have been better off without treatment. This statistic has been widely cited in prestigious journals such as the Journal of Clinical Psychiatry and American Psychologist, yet, as the authors of What has become of grief counseling? make clear in their article, there is very little support for these numbers. Their close examination yielded some troubling findings: Neimeyer's oft-cited article did not contain the statistics that it was based on. Instead, diligent digging revealed that the statistic was published only in a thesis, and not in a peer-reviewed journal. The flimsiness of this statistic, so central to the arguement of psychotherapy's risk, should be taken as a warning that all such claims must be carefully evaluated before laying heavy conclusions upon them.

The subject of deterioration effects is understudied. Psychiatry and psychology have not spent enough time proving the efficacy of the treatments that have become mainstays in working with the mentally anguished. But as Begley points out, that type of critical work needs to happen. It will make for better treatments and better service to clients. As Lillenfeld and others have shown, the bulk of the negative outcomes arise from methods that have not been rigorously tested, but even for the most well vetted therapies, there may be those clients who do not respond well. Good therapists will work with clients to find an approach that will work, and will be attuned enough to the course of each individuals' progress to know when something may be amiss.

By continuing to look for places to improve, therapists and others in the field of mental health will only further legitimize their science and empower practitioners to do more good in the future. The movement for this scientific validation needs to come from a collective effort on the part of all the stakeholders in behavioral health. They include employers, employees and health care providers. It is these stakeholders that are at the center of the Consumer Directed Health movement.

 

[David Baxter PhD]

I agree fully with the article above. The Newsweek article is based om crap science and consequently fatally flawed, in my opinion. Here it is; form your own opinion:

Get Shrunk at Your Own Risk
By Sharon Begley, Newsweek
June 18, 2007

No one bats an eye when a drug for a severe mental illness such as schizophrenia or depression causes serious side effects such as nausea, weight gain, blurred vision or a vanishing libido. But what few patients seeking psychotherapy know is that talking can be dangerous, too—and therapists have not exactly rushed to tell them so.

For treatments that come in a bottle, the Food and Drug Administration requires proof of safety and efficacy. For treatments that come from the lips of psychologists and psychiatrists, there's no such requirement. But while therapists fight over whether they should use only treatments for which there is rigorous scientific evidence for efficacy, they have largely ignored something more fundamental. "The profession hasn't shown much interest in the problem of treatments that can be harmful," says psychology professor Scott Lilienfeld of Emory University. "Of the few psychotherapies that have been tested for safety, too many cause harm to at least some patients."

The failure to heed Hippocrates reflects the assumption that psychotherapy is, at worst, innocuous. That naive trust should have been blown out of the water when "recovered memory" therapy actually created false memories, often of childhood sexual abuse, tearing families apart. But the Handbook of Psychotherapy and Behavior Therapy, the clinicians' bible, devotes only 2.5 pages out of 821 to adverse effects, even though documented risks of therapies could fill a small book.

"Stress debriefing," for instance, is designed to prevent symptoms of posttraumatic stress disorder in those who have suffered or witnessed a trauma. In a three- to four-hour group session, a therapist pushes patients to discuss and "process" their feelings and to describe in detail what they experienced or witnessed. Many of those who undergo stress debriefing develop worse PTSD symptoms than those who deal with the trauma on their own, controlled studies show, probably because the intense reliving of the trauma impedes natural recovery. Burn victims who underwent stress debriefing, for instance, had worse PTSD 13 months later than victims who had no psychotherapy; people who went through it after being in a car crash had greater anxiety about travel three years later than those who did not.

Psychotherapy for dissociative-identity disorder (formerly called multiple-personality disorder) can pose even greater risks. Some therapists believe that the best treatment for these fractured souls is to bring out the hidden identities, called "alters," through hypnosis or helping alters leave messages for one another. Unfortunately, many alters cause "self-injurious behavior, suicide attempts, and verbal and physical aggression," notes Lilienfeld in a paper in the journal Perspectives on Psychological Science. In addition, the "let's meet the alters!" techniques can actually create alters in suggestible patients. "As more alters come out, it gets harder to get the patient back to having one identity," Lilienfeld says. The longer someone stays in therapy, the more alters show up, evidence that "many and perhaps most alters are products of inadvertent therapist suggestion." So much for "First, do no harm."

Few of us will need therapy for multiple-personality disorder. But everyone will experience grief—and counseling for normal bereavement may not always be benign. A 2000 study found that four in 10 people who lost a loved one would have been better off without grief counseling (based on a comparison with people who were randomly assigned to a no-therapy group). That was especially so for those who experienced normal grief. In that case, counseling sometimes prolonged and deepened grief, leaving more depression and anxiety than in those who worked through their loss on their own.

That 40 percent figure is likely inflated, argues psychologist Dale Larson of Santa Clara University. But he agrees with Lilienfeld's estimate that 10 to 20 percent of people who receive psychotherapy are harmed by it. Even the American Psychological Association acknowledges that too many clinicians practice "psychoquackery," as psychologist John Norcross of Scranton University puts it. If we had FDA-style regulation of psychotherapies—difficult though that would be to do, especially since the effects of psychotherapy depend on the therapist—"fringe therapies would not be on the market."

How fringe is "fringe"? In percentage terms, very. But the number of people undergoing potentially risky therapies reaches into the tens of thousands. Vioxx was yanked from the market for less. To be sure, even risky psychotherapies don't harm everyone, just as most people who took Vioxx will never have a heart attack. What is remarkable about psychotherapies, though, is that few patients have any idea that "just talking" can be dangerous to their mental health.

 

[Cat Dancer]

An article like that could be totally discouraging to someone like me, who suffers from OCD and anxiety and blows things out of proportion. I agree with you though, it's a flawed article.

 

[Into The Light]

He goes beyond just debunking the curative power of dubious methods like eye movement desensitization and reprocessing to claim that many patients are actually harmed by their treatments.

i thought emdr was a valid type of therapy?

 

[David Baxter PhD]

EMDR is a relatively new treatment for PTSD. In my opinion, the jury is still out as to its effectiveness.

 

[Into The Light]

is it intended for just ptsd?

 

[David Baxter PhD]

Yes. Although some people seem to be exploring using it for other purposes.

 

[ThatLady]

A 2000 study found that four in 10 people who lost a loved one would have been better off without grief counseling (based on a comparison with people who were randomly assigned to a no-therapy group). That was especially so for those who experienced normal grief. In that case, counseling sometimes prolonged and deepened grief, leaving more depression and anxiety than in those who worked through their loss on their own.

I can't speak to the issue of psychotherapy, but I can certainly speak to the issue of grief and grief counselling. The entire premise of the above quote is flawed, in my opinion. Who is going to be doing in-depth counselling for someone whose grief process is proceeding normally? Nobody - that's who!

When someone suffers a loss, it's inevitable that they will grieve. For most people, grief is a process and proceeds along its course according to the needs of the individual who is grieving. Usually, people are able to work through their grief with the help of their pre-formed support system. Family members and friends are invaluable. If little glitches develop along the line, the person may reach out for professional help; however, it usually just involves talking out the problem they're trying to deal with. They'll then pick up where they left off and continue on the path to wellness.

There are, however, those who get "stuck" somewhere along the way. Perhaps, they don't have a very good support system, or none at all. Perhaps, they just can't move on for reasons that are as individual as they are. These people do, in fact, need counselling to complete the grieving process and return to living life. Without that counselling, they'll stay "stuck" and unable to cope with the loss they've suffered. In my experience, these people inevitably are helped by grief counselling.

 

[David Baxter PhD]

Excellent observations, TL.

 

[stargazer]

I know that I, for one, would have been much better off after Mom died had I been able to find good grief counseling. I remember being angry after she died, and my anger was amplified when a series of alleged grief counselors seemed to have different agendae. I kept asking: "When are we going to talk about my Mom?" And they said: "We'll get to that."

In hindsight, I think that it my scattered state of mind at the time would logically have become the focus of the counseling, and would also have prevented me from stating my needs clearly. But from my perspective at the time, the fact that I wasn't able to sit in one-to-one therapy and talk entirely about my Mom only aggravated my anger issues. Is it common for someone to be a grief counselor and yet not deal entirely with grief? Couldn't s(he) have led me back to the subject, rather than flow with my own incoherence and frazzledness? It was too much for me at the time. I think it had a lot to do with my eventually losing all my work and landing in those psych wards. I wasn't that way before Mom died, and I wasn't that way before all the failed attempts at finding a grief counselor.