Iatrogenic Harm in Psychotherapy

Unlike psychiatric drugs, psychotherapy is generally assumed to be safe and have little or no harmful side effects. Iatrogenic effects of psychotherapy are, in fact, well documented and even include death. Potential sources of iatrogenic harm in psychotherapy are: medicalizing and pathologizing ordinary human emotions, altering a client’s beliefs about the nature of their suffering, and learned dependence on the therapist. If therapists wish to help clients deal with emotional suffering, they must be aware of the potential for unintended harm. Just as psychotherapists bring awareness to the negative forces affecting a client’s emotional state, so too therapists must be made aware of the negative forces affecting the practice of psychotherapy.

Does Psychotherapy Cause Harm?

In 2001, a ten-year-old girl, Candice Newmaker, was diagnosed with Reactive Detachment Disorder. As part of her therapy, Candice was forcibly restrained, taunted, and smothered to death during a 70-minute “rebirth therapy” session. During the “rebirth” session, two therapists, and two therapy assistants wrapped Candice in blankets, surrounded her with pillows, and told her to struggle to set herself free in order to be “reborn.” Despite Candice’s lamentations that she could not breathe, needed air, and did not want to be “reborn”, the therapists and therapist assistants continued to put pressure on her and eventually crushed her with a combined weight of 670-pounds. The coroner concluded: death by asphyxiation (Josefson, 2001). 

The harm done by psychotherapy is typically not so acute or extreme as in the case of Candice Newmaker (Barlow, 2010). Even so, psychotherapists should be aware of the potential for iatrogenic harm in psychotherapy. While psychotherapy has the noble aim of reducing emotional suffering, it is important for therapists to recognize the limitations of their practice. By understanding the potential for iatrogenic harm, therapists can increase their effectiveness and limit adverse side effects (Lilienfeld, 2007).

Medicalizing and Pathologizing

One potential opportunity for iatrogenic harm in psychotherapy is the medicalization and pathologization of ordinary human behavior and emotions (Szasz, 1960). The process of medicalization in psychotherapy occurs when behavior that was once considered ordinary comes to be considered pathology (Szasz, 2007). Since 1952, the Diagnostic and Statistical Manual has attempted to differentiate between normal and abnormal emotions and behaviors. Critics of diagnostic labels have noted the ever-expanding list of human emotions and behaviors that are now classified as psychological disorders (Berk & Parker, 2009). While labels may be valuable for classifying disorders, they can also serve as self-fulfilling prophecies for clients receiving psychotherapy (Boisert & Faust, 2002). Pathologizing ordinary human suffering may cause a client to experience increased suffering if they come to believe that they are more mentally disturbed than they truly are (Boisert & Faust, 2002).

Adlerian psychologist, Rudolf Dreikurs, suggested that the medical model was inadequate for understanding psychological suffering (1977). The medical model seeks to extricate emotional disturbance from the client by labeling their suffering an illness (Dreikurs, 1977). In the medical model, the process of overcoming psychological disturbance is akin to removing a diseased appendix from the body (Udchic, 1984). 

Contrary to the medical model, Dreikurs describes emotional disturbance as intricately connected to the core personality of the suffering client. He saw psychiatric labels as pretense and metaphor rather than actual diseases. When trying to understand the desire to attribute emotional disturbance to disease Dreikurs said, “It is preferable to be sick and diseased, rather than to have one’s deficiencies discovered” (1977, p. 181).  Through the process of medicalizing and pathologizing emotional disturbances, a therapist may inadvertently encourage a client to assume the role of a sick patient. The client may unwittingly express more symptoms commonly attributed to their illness, prolonging the natural course of their original emotional distress (Boisert & Faust, 2002).

Influencing Beliefs

Another potential for iatrogenic harm in psychotherapy is in the process of altering a client’s beliefs about the nature of one’s emotional disturbance. For example, telling a client that they are “mentally ill” may encourage the client to begin assuming the “sick role”. As the client begins to take on the role of a “sick” patient, they may become increasingly reluctant to talk with family or other support about their emotional problems, for fear of the stigma associated with being diagnosed with a mental illness (Boisert & Faust, 2002).

In addition, therapists may offer idiosyncratic interpretations about the nature of a client’s emotional suffering. A client, who is in distress and vulnerable, may be open to suggestions about the therapist’s idiosyncratic interpretation (Boisert & Faust, 2002). While the interpretation may be meaningful to the therapist, it may be at odds with empirical research (Lilienfeld, 2007).

Learned Dependence on Therapist

Another potential for harm in psychotherapy is learned dependence on the therapist. During psychotherapy, clients may learn to depend on the psychotherapist for their emotional well-being (Barlow, 2010). A client may believe that the therapist has special curative powers, when in fact, the therapist may have little knowledge or experience with the client’s particular emotional disturbance. Rather than experiencing more autonomy in life, a client may become increasingly reliant on the therapist for navigating through mundane life decisions (Berk & Parker, 2009). The potential for learned dependence increases with therapies that involve frequent visits over extended periods of time, such as in the psychoanalytic approach (Berk & Parker, 2009).

Strategies to Reduce Iatrogenic Harm in Psychotherapy

To reduce harm in therapy, therapists must take active steps to limit the potential for harm. Since psychotherapy is highly individual in nature, therapists have the ability to customize treatment based on the client’s progress (Barlow, 2010). Lilienfeld (2007) suggests that tracking a client’s progress during psychotherapy is essential to limit the possible harmful side effects of therapy. By administering questionnaires during each session, a therapist can assess the progress of the client. Questionnaires provide therapists and clients with early warning signs of potential iatrogenic harm. If a client is deteriorating emotionally, the therapist or client can make changes to the treatment (Lilienfeld, 2007).

Recognizing the limitations of the medical model of psychopathology is another important aspect for warding off undesirable effects of psychotherapy (Dreikurs, 1977). Therapists must use caution when applying diagnostic labels to clients, lest they create a self-fulfilling prophecy (Boisert & Faust, 2002). Dreikurs suggested that therapists should strive to understand the client as a whole by considering the client’s symptoms within the greater narrative of the client’s life story and personality (Udchic, 1984).

Conclusion

The potential for iatrogenic harm in psychotherapy is pervasive. Psychotherapists must exercise caution so as not to cause unnecessary harm during psychotherapy. Potential opportunities for unintended harm in psychotherapy are: medicalizing ordinary human emotions, altering a client’s beliefs about the nature of their suffering, and learned dependence on the therapist. Some important steps that a therapist can take to limit harm are: tracking client progress, limiting medicalization of emotional disturbances, and taking a holistic approach to emotional distress (Dreikurs, 1977, Lilienfeld, 2007). 

While psychotherapy has an honorable goal of helping people deal with emotional distress, therapists must recognize the potential for harm if they wish to help their clients. Psychotherapists who seek to avoid iatrogenic harm must be willing to analyze the practice of psychotherapy with the same intensity that they use when analyzing their clients.

References

Barlow, D. (2010, January). Negative Effects From Psychological Treatments: A Perspective. American Psychologist, 65(1), 13-20.

Berk, M., & Parker, G. (2009). The Elephant on the Couch: Side-effects of Psychotherapy. Australian & New Zealand Journal of Psychiatry, 43(9), 787-794.

Boisert, C. M., & Faust, D. (2002, Spring). Iatrogenic Symptoms in Psychotherapy: A Theoretical Exploration of the Potential Impact of Labels, Language, and Belief Systems. American Journal of Psychotherapy, 56(2), 244.

Dreikurs, R. (1977, November). Holistic Medicine and the Function of Neurosis. Journal of Individual Psychology, 33(2), 171.

Josefson, D. (2001, April 28). Rebirthing Therapy Banned after Girl Died in 70 Minute Struggle. British Medical Journal, 322(7293), 1014.

Lilienfeld, S. (2007, March). Psychological Treatments That Cause Harm. Perspectives on Psychological Science, 2(1), 53-70.

Szasz TS. The myth of mental illness. Am Psychol 1960; 15: 113–118.

Szasz T. The Medicalization of Everyday Life: Selected Essays. Syracuse University Press, 2007.

Udchic, H. (1984, December). Adlerian Holism and Holistic Health. Individual Psychology: The Journal of Adlerian Theory, Research & Practice., 40(4), 364.

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