Reflecting my day job, I’m going to focus here on mood disorders. Some of these (melancholic depression, for instance, and bipolar disorder) are essentially “diseases” because their causes are largely genetic, and reflect primary biological brain changes.
The wrong model
People with these mood disorders tend to respond to medication but not usually to talking therapies. Therapists with a narrow treatment approach will generally fail to be of any assistance to people who suffer from such conditions.
But sadly, as per the aphorism “if all you have is a hammer, then everything looks like a nail”, some therapists reject any possibility they might be providing totally inappropriate treatment.
I cringe when recipients of such treatment – many substantially impaired for years – tell me their practitioner has reassured them that their continuing depression (which might have responded within weeks to an antidepressant drug) needs to be “experienced before it can be worked through,” or some other defensive pseudo-profound explanation.
In such cases, talking therapies are indirectly harmful by being inappropriate and ineffective.
Conversely, there are many depressive disorders that lack primary biological changes. But, despite the most appropriate treatment here being a talking therapy, the individual receives a procession of inappropriate and ineffective antidepressant drugs that may also have distressing side effects.
Here again, harm – and a lack of therapeutic response – may arise from the wrong therapeutic model. But harm may also accrue from the ingredients of therapy and how they’re applied by individual therapists.
Components and risks
Psychotherapies, such as cognitive behaviour therapy or dynamic psychotherapy, are all developed with an underlying logic and possess powerful specific ingredients.
Cognitive behaviour therapy, for instance, challenges faulty thinking patterns that cause people to view themselves, their future, and the world negatively. While dynamic psychotherapy, which is derived from psychoanalysis, is designed to identify the early formative events that led the individual to develop psychological problems.
But all psychotherapies also contain non-specific therapeutic ingredients that may – when present in some circumstances, or absent in others – benefit or harm the patient. These include the therapist being empathic, and providing a clear therapeutic rationale in a healing and restorative setting.
An analysis of several studies shows only 8% of patient improvement during psychotherapy is due to any specific therapy component.
Other research puts the figure at an estimated 15%, with the remainder emerging from non-specific components – a third from the therapeutic relationship, and some from patients “expecting” to improve, but most improvement from patient and extra-therapy factors such as the therapist being empathic, offering a logical model, hope and expectancy of improvement.
But just as the ideal therapist can contribute significantly to improvement, if he or she lacks such ingredients – or is actively “toxic” – then harm occurs.
Psychotherapists argue that because their work is “only talking… no possible harm could ensue”. But all effective medication is accompanied by risk and the same holds for talking therapies.
The harm of talking therapies
In 2009, a colleague and I published an overview of reported harmful effects from talking therapies, examining scenarios such as the insensitive, critical, voyeuristic or sexually exploitative therapist, and their prevalence.
In a subsequent research report, we developed a measure of adverse therapeutic styles experienced by people who had received a psychological therapy and left or (perhaps more concerning), remained in therapy and had their condition worsen.
The most common “negative therapist” style identified was a lack of empathy or respect, and not having the patient’s interests at heart.
Next, was the “preoccupied therapist” who made the patient feel alienated and powerless; the controlling therapist who encouraged dependency; and, finally, the passive therapist who was inactive, inexperienced or lacked credibility.
While side effects from medicines are generally physical, the adverse effects of psychotherapy and counselling naturally tilt to the psychological. They tend to leave the harmed person inclined to feel self-blame, helpless, and demoralised (or to become more self-centred and self-absorbed), while commonly remaining dependent on the therapist.
To avoid this, all health practitioners should be evaluated by their clients in terms of both style and substance. Most patients seek practitioners who meets both requirements; who are perceived as caring and technically proficient. But, if invited to choose which to prioritise, most will generally go for “style” (preferring the kindly practitioner).
This is also a matter of concern; kindly practitioners may meander without a therapeutic game plan so that, while the patient is appreciating their warmth, there is no actual progress.
Unfortunately, there are no formal processes in place for evaluating professional psychotherapists and counsellors. While a therapist would not (and could not) allow an independent observer to judge the therapy on a session by session basis, there’s no reason why a patient cannot seek a second opinion from another therapist to determine if the therapy being received is cogent and provided at a professionally logical level.
Informal ratings provided on platforms, such as websites, should not necessarily be trusted because ratings may be weighted to the aggrieved (satisfied customers are less likely to rate), and professional rivals may “load” negative reports.
If someone is exploited or abused by a therapist, they should make a report to the appropriate professional disciplinary board. If the therapist is less overtly concerning (whether simply passive, on the wrong wavelength or causing you to feel troubled or even worse), best to cut and run.
You may have psychological problems but rely on your instincts; therapy that matches your needs is an incomparable balm and will advance your recovery. Therapy that fails this is not worth your while.
Gordon Parker is founder of the Black Dog Institute and Scientia Professor at UNSW.
This opinion piece was first published in The Conversation.