There are some hidden risks in agreeing to have psychotherapy, and they occasionally have serious consequences.
Yesterday in Jeopardy I wrote about the Health Professions Council (HPC), which claims to protect the public while in reality colluding with low standards in the NHS. Psychotherapy is not yet ‘regulated’ by the HPC. When it is, the problems that the HPC causes will affect psychotherapists too.
But psychotherapy can cause direct harm to patients. Arguably, the public does need some protection from psychotherapists. The trouble is that the kind of protection on offer from the HPC does not address the potential harm that psychotherapy can cause.
Just to be clear, this post is not about criminal offences like theft and forgery that the HPC concerns itself with. Nor is it about employment issues like lateness and poor record-keeping. It is not even about unprofessional behaviour that might sometimes occur when you consult any kind of professional. This post is about forms of harm that are specific to psychotherapy.
The two that I hear about most often are what I’ll call dependency and overlay.
Dependency is when you attend psychotherapy in order to overcome some difficulty, but the therapy becomes an end in itself, and you continue having therapy for a greatly extended period. Many victims of dependency end up attending therapy unnecessarily for years, and a few for decades.
Therapy that makes you dependent maintains your condition as a perpetual patient. It might or might not treat the original condition.
It can be difficult to distinguish between dependency and genuinely long-term therapy. Long-term therapy is required when your condition is very complex. (Personality disorders are examples of complex conditions.) It’s hard for you to know whether your condition is complex or not, so a better way to avoid dependency is to look out for specific signs. I outlined some of them here in Recession.
As a patient, dependency gives you the feeing that you cannot imagine life without therapy. It’s as if therapy becomes an addiction.
There is very often a strong element of personal connection with your therapist. You start to feel as if the main purpose of therapy is for you to relate to your therapist, not that it is for you to overcome your original difficulty.
Dependency is often associated with psychodynamic therapy, because psychodynamic techniques can be very slow even for relatively simple conditions, making dependency easier to conceal. It is certainly not the case that all psychodynamic therapy creates dependency, but its nature makes it somewhat more risky.
CBT generally works in a matter of weeks or months, so there is very little opportunity for dependency to occur. Indeed, even when CBT takes months, definite signs of improvement are usually evident after only a few weeks. There’s a continual feeling of things moving forward, changing for the better, and an expectation that the success you achieve is for you to take with you when you finish therapy.
Overlay is when you attend psychotherapy in order to overcome some difficulty, but the therapy overlays your original difficulty with some other difficulty.
The overlaid difficulty cannot be described as an illness, so you cannot be treated for it. Instead, you come to believe that your difficulties are your own fault, and you can only overcome them by trying harder. Therefore you avoid further treatment and continue to struggle. It’s like dependency, but instead of becoming dependent on the therapist, you become dependent on the treatment.
For example, you might attend psychotherapy because you feel anxious. Your therapist teaches you that you can overcome anxiety by using certain exercises, and off you go. The exercises do not work, but you have been led to believe that this is because you are not doing them properly, and if you only try harder they will eventually work. So you still struggle with anxiety, and you struggle with the exercises too.
Overlay techniques sometimes do alleviate the original condition or some of its symptoms. For example, if you have an eating disorder then techniques that involve you trying hard to maintain a healthy weight might really achieve that, at least to a limited extent. But overlay techniques do not address the underlying mental illness. In some cases the underlying illness just goes away after time, but not always.
You can easily detect overlay techniques. They give you the responsibility to live your life in a certain way, or to monitor your condition constantly and take action to regulate it. As a patient, overlay techniques leave your original mental state essentially unchanged, and pass the responsibility on to you to control the symptoms.
CBT addresses the root cause of a mental illness. After the root cause has been dealt with, a CBT therapist might work with you to mop up the residual symptoms, and this might involve teaching you practical techniques that you can use in the short term or very occasionally after that. But these practical techniques are not a way of life. The goal of CBT is that you should be genuinely free of your illness, able to live the rest of your life careless of it.
Dependency and overlay techniques harm you by making you struggle with your illness for far longer than is necessary — perhaps forever if they make you avoid seeking proper treatment. Some treatments are harmful in a lesser way, mainly wasting your time (and money, perhaps).
Superficial treatments are in this category. These are genuine treatments that only partly work. So they are OK for simple cases. Unfortunately you might be referred for a superficial treatment even if your case is serious, especially in the NHS.
There are various types. Fixed-length treatments, group treatments and online treatments are almost always superficial. Other treatments that fail to address why your illness makes you feel the way you do are also superficial.
These treatments do sometimes work, especially if your condition is simple. Sometimes they work for a while and then you relapse.
CBT always addresses why your illness makes you feel the way you do. It is never fixed in length, always one-to-one, and never online. (Telephone CBT is a grey area that I wrote about in Telephony.)
Misdiagnosis is another harmful practice that mainly wastes your time (and money, perhaps).
For example, something bad happens to you and makes you depressed. Your depression is misdiagnosed as a chemical imbalance requiring drug treatment, when it is really a reaction to the bad event. Now you are stuck on medication that is never going to work. It might suppress your symptoms while you keep taking it, but as soon as you stop, that bad event is still there in your past and no one has helped you to deal with the feelings it causes.
It’s almost impossible for you to detect misdiagnosis directly. One indirect clue is if the person who diagnosed you was not a consultant psychiatrist. Another is if the person who diagnosed you did not seem to really understand you, how you think and how you feel. Another is if you participate fully in the resulting treatment, but it does not work.
CBT does not depend on diagnosis, because diagnosis is almost no help in determining the root cause of a mental illness. In CBT the difficulties you have are treated as personal to you. Misdiagnosis becomes irrelevant.
In CBT there are sometimes false starts, when you identify what seems to be a root cause, but it turns out not to be. This is part of the process of guided self-discovery in the early stages of CBT treatment, and it’s not harmful.
Then there’s plain incompetence. Some therapists go through the motions and just get nowhere. Again, it wastes your time (and money, perhaps).
For example, you might attend therapy for several months and find that nothing happens at all. You are not dependent on therapy, you have not been made to feel that you must live your life a certain way, the treatment seemed to be in-depth, and you were not misdiagnosed, but nothing happened. Your problems are just as bad.
You can sometimes detect incompetence because your therapist does not seem to be doing any of the work. If you are doing all the work in therapy, and your therapist is having an easy time of it, take that as a warning sign. Effective therapy requires your therapist to work hard at connecting with you and understanding you throughout every session.
You can guard against incompetence if your therapist is personally recommended to you by someone you know well and trust who has had successful treatment, or by a doctor who has referred similar patients who were treated successfully.
You can also guard against it with private practitioners by choosing a therapist who has been in business for several years. Incompetent therapists tend not to survive in business on their own (unless they create dependency), and they generally end up in employment.
There’s nothing about CBT that guarantees CBT therapists will all be competent. Accreditation on the CBT Register is a positive sign. Academic training, with degrees and certificates, does not help (and may even be a hindrance).
With all of these harmful practices, the important thing is to move on and find effective treatment, even though dependency and overlay techniques tend to make this difficult. And with all of these harmful practices, there are therapists claiming that their harmful therapy is CBT when it is not (though this is less true of therapists who create dependency).
The hidden risks in psychotherapy are not such huge risks that they remove all hope of becoming well. Anyone mentally capable of appreciating the risks is capable of seeing through harmful therapies and recovering.