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date: 22 October 2017

Potentially Harmful Treatments

Summary and Keywords

Although psychotherapy is on balance effective for a broad array of psychological problems, a relatively small but steadily accumulating body of evidence suggests that at least some psychological interventions are harmful. Until recently, however, relatively little research attention has been paid to the identification of harmful psychological treatments. Although it has long been recognized that a nontrivial minority of people become worse following therapy, this finding does not necessarily mean that they have become worse because of therapy. Nevertheless, recent research has homed in on a small subset of interventions that may produce psychological harm, physical harm, or both. In addition, there is growing interest in pinpointing potential mechanisms of deterioration effects in psychotherapy, as well as in distinguishing harmful therapies from harmful therapists.

Keywords: Psychotherapy, effectiveness of therapy, iatrogenic, deterioration, randomized controlled trial, recovered memories, dissociative identity disorder

A client who is experiencing mild to moderate symptoms of depression, persistent anxiety regarding her marriage and work, and intermittent bouts of overeating, scours the Internet for a potential psychotherapist. She finds a listing for a therapist in her hometown and calls him to set up an initial appointment. Is there any risk that he might inadvertently make her psychological problems worse?

A sizeable plurality of psychotherapists would probably answer “No” (Boisvert & Faust, 2006; but see Bystedt, Rozental, Andersson, Boettcher, & Carlbring, 2014). This response is understandable given that there is compelling evidence that a broad swath of psychotherapeutic modalities are beneficial for a diverse array of psychological conditions (Smith, Glass, & Miller, , 1980; Wampold, 2013). Indeed, the odds are high that her therapist, if adequately trained in evidence-based techniques, will be able to help her (Chambless & Ollendick, 2001). Nevertheless, there is mounting evidence that at least a small proportion of psychological treatments may be “iatrogenic,” that is, harmful (“iatrogenic” means “caused by a doctor”). Hence, the longstanding assumption that therapy is at worst innocuous is coming under increasing scrutiny (Dimidjian & Hollon, 2010; Lampropoulos, 2011; Lilienfeld, 2007).

At the same time, the question of which psychological treatments tend to be harmful and why is still poorly understood, largely because research on the positive effects of psychotherapy has greatly outstripped research on its potential negative effects. Moreover, far more is known about the potential harmful effects of psychotropic medications, such as the possible adverse impact of selective serotonin reuptake inhibitors on suicidal behavior among adolescents, than on the potential harmful effects of psychotherapy (Berk & Parker, 2009; Vaughan, Goldstein, Alikakos, Cohen, & Serby, 2014). This disparity in knowledge may in part reflect the assumption that because psychotherapy typically consists of little more than “talking,” it cannot exert iatrogenic effects (Nutt & Sharpe, 2008). As we will discover, this assumption is almost certainly erroneous.

Early Work on the Harmful Effects of Psychotherapy

The pioneering work of Bergin (1966; see also Stuart, 1970), which suggested that between 5 and 10% of patients typically became worse during or following psychotherapy, was the first to explicitly highlight the problem of what he termed “deterioration effects” in treatment (Barlow, 2010). In the 1970s, further challenges to the assumption that therapy is never harmful were raised by Strupp and colleagues, who referred to “negative effects” arising from therapy (Strupp, Hadley, & Gomez-Schwartz, 1978). They adopted this broader term to underscore the point that harmful therapeutic effects encompass more than client deterioration in signs and symptoms of psychopathology; they may also include marital problems, work conflicts, and reluctance to seek out future psychological help. Although the magnitudes of these ancillary sequelae are difficult to estimate, the best scientific consensus is that approximately 10% of clients typically become worse following psychotherapy (Mohr, 1995).

Nevertheless, this statement should not be taken to mean that about 10% of clients become worse as a result of psychotherapy, although a number of scholars have erroneously drawn this inference. The confusion between these two statements exemplifies what logicians call the “post hoc, ergo propter hoc” (after this, therefore because of this) fallacy (Woods & Walton, 1977). This fallacy refers to the error of concluding that because event A came before event B, event A must have caused event B. The fact that all mass murderers drank milk as children does not mean that the practice of giving milk to children breeds mass murderers. Similarly, although the deterioration of a client in psychotherapy may have been due to the treatment, it may instead have been due to one or more extratherapeutic variables, such as stressful life events, medical complications, or the natural course of the client’s disorder. It is even possible that the therapy was effective, but that it slowed the pace of naturally occurring deterioration; in this case, unwary observers may deem a beneficial intervention to be detrimental. Hence, it is critical that iatrogenic effects be operationalized more rigorously than merely a worsening of the client’s psychopathology over the course of treatment.

There are several ways to detect harmful effects in psychotherapy outcome studies. The most straightforward evidence for such effects arises when a treatment consistently yields negative effect sizes relative to comparison groups in randomized controlled trials or carefully controlled quasi-experimental studies. Nevertheless, in other cases harmful effects may produce changes in variance rather than changes in means (Barlow, 2010; Lilienfeld, 2007). In such cases, an intervention may make certain clients better but other clients worse, with little or no change in the average levels of improvement. Still another way of inferring negative effects is to detect a sudden and dramatic negative change in psychological symptoms that coincides with the introduction of a treatment. Nevertheless, such an inference can be fallacious if the client’s symptoms are inherently unstable over time (Dimidjian & Hollon, 2010). For example, in clients with bipolar disorder or borderline personality disorder, which are conditions whose symptoms wax and wane markedly over brief time periods, it can be difficult to confidently attribute a worsening of symptoms to the treatment. Hence, inferences of iatrogenic effects in single case designs are most likely to be accurate when the client’s condition is relatively stable.

It is crucial that all psychotherapists remain alert to the possibility of client deterioration effects. This awareness is especially important in light of evidence that many psychotherapists dramatically underestimate the proportion of their clients who become worse in treatment (Walfish, McAlister, O’Donnell, & Lambert, 2012). As a consequence, many of them may neglect to undertake critical mid-course corrections that could place treatment back on the right track.

Defining and Operationalizing Harm

Defining harm in the context of psychological treatment is far more complicated than it might appear (Dimidjian & Hollon, 2010; Lilienfeld, 2007; Strupp, Hadley, & Gomez-Schwartz, 1978). Harm can be defined in multiple ways, many of which may be separable conceptually and empirically.

First, one must be certain to distinguish short-term from long-term deterioration effects. Some psychotherapeutic procedures that are effective in the long run may make a certain number of people worse in the short run. Some marital therapies often produce time-limited increases in relationship distress early in treatment, presumably because they encourage partners to confront long-avoided interpersonal conflicts (Hunsley & Lee, 1995). As another example, prolonged exposure (PE) is the best supported psychological intervention for posttraumatic stress disorder (Foa, Gillihan, & Bryant, 2013), but it tends to exacerbate anxiety symptoms in up to 20% of clients in the first few sessions. Fortunately, this short-term worsening is largely or entirely unrelated to long-term outcomes (Foa et al., 2002), which are typically positive. Regrettably, this crucial caveat was neglected in the widely read book by David Morris (2015), an Iraqi War veteran who developed posttraumatic stress disorder and who movingly described his own negative experiences with PE in the Veterans Affairs System. Morris reported that he experienced pronounced negative effects following his first few sessions of PE, including heightened agitation, anxiety, and insomnia. Nevertheless, he neglected to cite the research literature (Foa et al., 2002) suggesting that had he remained in treatment, he would have been likely to improve.

Second, “harm” is almost certainly a multidimensional concept. As noted earlier, harm can comprise worsening of the clinical features of a given disorder. Nevertheless, it can also include excessive dependency on therapists, reluctance to seek out future effective interventions, work and relationship conflicts, and in, very rare cases, physical harm (Boisvert, 2003).

Third, the concept of harm cannot be divorced entirely from societal and cultural values (Wendt, Gone, & Nagata, 2015). For example, in Western countries, heightened assertiveness in a woman with avoidant personality disorder who was reluctant to confront her husband regarding his repeated verbal abuse of her would presumably be regarded as a positive treatment effect. In contrast, in some Islamic countries, in which a wife’s subservience to her husband is typically regarded as a virtue, such increased assertiveness would probably be considered a negative treatment effect.

Fourth, some treatments may exert beneficial effects on certain outcomes but detrimental effects on others. Imagine a married couple who has developed a pathological dependency relationship: The wife suffers from severe agoraphobia that has left her largely housebound while her husband, who meets criteria for dependent personality disorder, has grown accustomed to having his wife attend promptly and dutifully to his emotional needs. As her agoraphobic features diminish in the wake of effective behavior therapy and she begins to venture out of the house more frequently, he may suddenly experience feelings of extreme loneliness or depression. Nevertheless, the research evidence for such mixed effects of psychological treatments is preliminary.

Fifth, some psychological techniques may be efficacious in isolation, but interfere with the efficacy of other techniques. For example, although relaxation training can be helpful for anxiety (Beck, Stanley, Baldwin, Deagle, & Averill, 1994; Manzoni, Pagnini, Castelnuovo, & Molinari, 2008), relaxation may impede the efficacy of exposure therapy (Barlow, 2010). This interference effect may arise because relaxation and other “safety behaviors” diminish the intensity of exposure, in turn hindering its ability to inhibit and “overwrite” previously learned maladaptive associations (Craske, Treanor, Conway, Zbozinek, & Vervliet, 2014). Still other methods may be generally efficacious but backfire in conjunction with other variables. For example, provisional data indicate that cognitive-behavioral therapy is helpful for early psychosis so long as the therapeutic alliance is positive, but that it may be detrimental when the therapeutic alliance is negative (Goldsmith, Lewis, Dunn, & Bentall, 2015). It will be crucial to determine if these findings stand the test of independent replication.

Sixth and finally, another important source of harm, albeit one that is not addressed in further detail here, collectively includes what economists term “opportunity costs.” Opportunity costs refer to the time, energy, effort, and resources expended in seeking out and receiving ineffective interventions (Donaldson, Currie, & Mitton, 2002). Opportunity costs are an important reminder that even interventions that are by themselves innocuous can generate substantial indirect harm. For example, energy therapies (e.g., Thought Field Therapy), which are based on the scientifically dubious premise that anxiety disorders and other psychological conditions are produced by blockages in invisible energy fields, may not be directly harmful. Nevertheless, they may deprive clients of valuable resources that could be better invested in interventions that are empirically supported. Moreover, although research on this possibility is lacking, it is plausible that some clients may attribute a lack of improvement following an ineffective intervention to a failure on their part rather than on the therapist’s part.

Potentially Harmful Treatments

In an initial effort to identify psychological interventions that pose a risk of harm to at least some clients, Lilienfeld (2007; see also Lilienfeld, Fowler, Lohr, & Lynn, 2005) laid out a preliminary list of potentially harmful treatments (PHTs): interventions that have been found to be iatrogenic in well-conducted research. He did so with the proviso that this list was provisional and would hopefully be refined by later scholars. As he noted, a treatment’s inclusion on the tentative PHT list should not be interpreted to imply that it is harmful for all or even most clients. Instead, a treatment’s designation as a PHT should give therapists who are considering administering this treatment pause or, at a minimum, remind them to “proceed with caution” when administering it.

To qualify as a PHT, Lilienfeld (2007) stipulated that a treatment be demonstrated to either (a) be harmful (that is, it produces symptom worsening) across independently replicated studies, ideally RCTs, or (b) result in marked increases in low base-rate adverse events (e.g., recovered memories of trauma) shortly following the introduction of the treatment across multiple case reports. Note that these criteria exclude harm arising exclusively from opportunity costs, which are indirect, and focus only on treatments that produce a clear-cut deterioration in psychopathology. The criteria for (a) will require clarification in further reviews of harmful interventions, as it is unclear whether a treatment that has been found to be effective in some controlled trials but directly harmful in several others should qualify as a PHT. The section that follows reviews six treatments that qualify as provisional PHTs in light of the present research evidence, as well as several other interventions that appear to be harmful in selected circumstances.

This list is by no means exhaustive. For example, a number of authors have raised concerns that certain interventions that have not been extensively studied in controlled trials, such as sexual reorientation therapy for gay clients (Flentje, Heck, & Cochran, 2014), Drug Abuse Resistance and Education (DARE) programs for schoolchildren (Werch & Owen, 2002), and certain Internet-based interventions (Rozental et al., 2014), generate negative psychological effects in at least some recipients. These treatments will require considerably closer research scrutiny to rule out the possibility of marked iatrogenic effects among subsets of individuals.

Critical Incident Stress Debriefing

Critical incident stress debriefing (CISD) is a widely used treatment designed to ward off symptoms of posttraumatic stress disorder (PTSD) among trauma-exposed individuals (Adler et al., 2008; McNally, Bryant, & Ehlers, 2003). Several thousand counselors administered CISD or its variants to the witnesses of the September 11th, 2001, terrorist attacks in New York City. CISD is typically conducted in a single group session soon after the traumatic event (typically within one to two days) and lasts several hours, although it is occasionally spread out across several sessions. In CISD, therapists typically urge group members to discuss and “process” their negative emotions associated with the trauma, describe the symptoms of PTSD that group members are likely to experience following trauma, and discourage group members from discontinuing participation once the session is underway.

A meta-analysis of RCTs for CISD yielded a slightly negative effect size (d = −.11) for PTSD symptoms, suggesting that trauma-exposed individuals who receive CISD end up with slightly more PTSD symptoms than do individuals who receive no treatment. The results of three randomized controlled trials (Bisson, Jenkins, Alexander, & Bannister, 1997; Mayou, Ehlers, & Hobbs, 2000; Sijbrandij, Olff, Reitsma, Carlier, & Gersons, 2006) indicate that CISD can be harmful for at least some trauma-exposed individuals. These findings will require independent replication, although they raise the possibility that CISD impedes natural coping and recovery processes (McNally et al., 2003). In a similar vein, scattered evidence from randomized controlled trials suggests that grief therapies, which similarly encourage the expression of intense negative affect following emotionally painful experiences, can be harmful for certain individuals experiencing largely normative mourning reactions (Neimeyer, 2000; but see Larson & Hoyt, 2007, for a different view).

Scared Straight Programs

Scared Straight Programs became popular in the 1970s, especially in the wake of an influential 1978 documentary (“Scared Straight!”) filmed at Rahway State Prison in New Jersey, where these programs originated. Scared Straight Programs attempt to frighten at-risk teenagers from a life of crime by exposing them first-hand to the harsh realities of prison life. Many of these programs introduce troubled adolescents to convicts in prison.

A meta-analysis of seven RCTs and quasi-experimental studies of Scared Straight programs revealed that that they increased the chances of reoffending by a ratio of between 1.6 and 1.7 to 1 (Petrosino & Turpin-Petrosino, 2000). The mechanisms underlying these apparent negative effects are unknown, although some authors have proposed that Scared Straight programs contribute to feelings of resentment and anger among a subgroup of teenagers who are already alienated. These programs may also inadvertently expose youth to role models for crime, who may impress at-risk adolescents as “tough” and as worth emulating.

The research evidence for other “get tough” interventions with troubled adolescents has been similarly mixed or negative. For example, the support for popular “boot camp” programs for adolescent criminals is exceedingly equivocal, with some studies showing significant positive effects but others showing significant negative effects (Bottcher & Ezell, 2005; Parent, 2003). The reasons for these discrepancies across studies are unclear. Nevertheless, delinquency programs that emphasize harsh discipline without providing adolescents with constructive coping skills tend to be ineffective or harmful (Lipsey, 2009).

Facilitated Communication

Although not traditionally regarded as a psychotherapy per se, facilitated communication (FC) is based on an entirely unsubstantiated and implausible theory regarding autism spectrum disorder and related developmental disabilities, namely, that autism is primarily a motor, not a mental, disorder. According to FC proponents (e.g., Biklen, 1990), individuals with autism suffer from a hypothesized condition called “developmental apraxia,” which accounts for their weak or absent verbal abilities, as well as their other movement difficulties. Hence, with the assistance of a trained facilitator who steadies the individual’s hands and arms, individuals with autism spectrum disorder and similar developmental disabilities who were previously believed to be mute can suddenly display “hidden literacy,” purportedly generating complex sentences and paragraphs with a computer keyboard or letter pad.

Nevertheless, controlled studies in which individuals with autism spectrum disorder and their facilitator were shown different stimuli (e.g., a dog versus a cat) and were asked to type which stimulus they saw provide overwhelming evidence for unintentional facilitator influence over autistic individuals’ communications—an “ideomotor” or “Ouija board” effect (Herbert, Sharp, & Gaudiano, 2002; Lilienfeld, 2005). Specifically, in all well-controlled studies, the word typed corresponded in essentially all cases to the stimulus viewed by the facilitator, not by the autistic individual. There is no evidence that facilitated communications are generated by autistic individuals themselves. Moreover, FC has been associated with at least five dozen allegations of sexual abuse against the parents and relatives of autistic children, most of which have not been corroborated by objective evidence (Jacobson, Mulick, & Schwartz, 1995; Mostert, 2010). The striking absence of evidence for the efficacy of FC notwithstanding, this technique continues to be widely used in many quarters; according to some surveys, it is still administered to up to 10% of children with autism spectrum disorder (Lilienfeld, Marshall, Todd, & Shane, 2014).

Coercive Restraint Therapies

Coercive restraint therapies (CRTs) are a subset of attachment therapies, which are based on the unsupported notion that certain psychological difficulties, including physical aggression and oppositionality, stem from aberrant early emotional attachment experiences. These experiences purportedly include a premature or abnormally difficult birth (Mercer, 2002). CRTs, like other attachment therapies, are intended to ameliorate the psychological effects of these adverse experiences. CRTs include holding therapy, in which therapists physically restrain children or adolescents in an effort to release suppressed rage (Mercer, 2013), and rebirthing therapy, in which therapists attempt to engage the client in reenacting the trauma of birth (Sharpless & Barber, 2009). In some variants of rebirthing therapy, practitioners wrap the child in blankets to create an analogue birth canal and simulate the birth process by squeezing on them repeatedly.

There are no controlled studies supporting the efficacy of CRTs or other attachment therapies (Mercer, 2002). Moreover, several children, including 10-year old Candace Newmaker in Colorado in 2000, have been suffocated to death or injured during CRTs (in Candace’s case, rebirthing; see Mercer, Sarner, & Rosa, 2003).

Suggestive Techniques for Memory Recovery

Several surveys from the 1990s suggest that a sizeable proportion, perhaps 25%, of therapists made regular use of suggestive techniques to unearth purportedly recovered memories of early trauma, particularly child sexual abuse (Polusny & Folette, 1996; Poole, Lindsay, Memon, & Bull, 1995). These therapeutic methods include repeated therapist prompting of memories, hypnosis (including hypnotic age regression), the use of “truth serum” (a misnamed class of drugs that include sodium amytal and other barbiturates), guided imagery, and “body work,” which encourages clients to access supposed “body memories” of early abuse (Lynn, Lock, Loftus, Krackow, & Lilienfeld, 2014). It is unknown whether the rates of use of such techniques has declined since the 1990s, although sizeable proportions of therapists, especially those of psychodynamic orientations, continue to believe in the reality of recovered memories of abuse (Patihis, Ho, Tingen, Lilienfeld, & Loftus, 2014).

The question of whether suggestive techniques sometimes exhume veridical memories of abuse remains scientifically controversial (Geraerts et al., 2006; McNally et al., 2003). Nevertheless, laboratory research using suggestive memory procedures, such as repeated prompting of imaginary recollections, leaves little doubt that these techniques can lead to false memories in a substantial percentage of participants (Lynn, Lock, Loftus, Krackow, & Lilienfeld, 2014). Moreover, findings that recovered memory techniques can engender memories of past-life child abuse (Spanos, 1994) offer potent “existence proofs” that at least some of the memories produced by these techniques are false.

There is ample reason to believe that false memories can lead to marked harmful effects in both clients and their family members. Data from recovered memory legal claims in the state of Washington reveal that suicidal ideation increased nearly sevenfold and that psychiatric hospitalizations increased nearly fivefold over the course of recovered memory treatment (Dineen, 2001). Although not allowing conclusive evidence of causality, these findings raise serious concerns about the potential negative effects of such treatment. Moreover, numerous families have been—and continue to be (Ammirati & Lilienfeld, 2015)—torn apart by uncorroborated accusations of sexual abuse by children against parents (Loftus & Ketcham, 1994).

Alter Reification

Alter reification is designed to elicit purported alter personalities (“alters”) in individuals suspected to meet criteria for dissociative identity disorder (DID), known formerly as multiple personality disorder. The assumption is that with DID harbor hidden identities that must be excavated and brought to light for improvement to occur. Alter reification methods include a variety of suggestive treatment techniques, including contacting supposed alters through hypnosis, introducing alters to each other, referring to alters by different names, and mapping out the relations among alters (Lilienfeld et al., 1999; Piper, 1997; Spanos, 1994). One prominent DID therapist advocates the use of a “bulletin board” to allow alters to post messages to each other (Putnam, 1989), and another lobbies for the use “inner board meetings” as a method of permitting alters to communicate with each other (Ross, 1997).

Large bodies of evidence, however, suggest that alter reification helps to “bring forth” poorly integrated aspects of DID patients’ personalities, thereby presumably serving to create alters rather than to unearth them (Paris, 2012; Lilienfeld & Lynn, 2014). Interestingly, only about 20% of patients with DID display clear-cut alters prior to treatment, and such alters emerge in the remaining 80% of patients only following therapy intended to reify alters (Kluft, 1984). In addition, the number of alters tends to increase over the course of therapy, raising the distinct possibility that alter reification techniques are exacerbating their symptoms (Piper, 1997). This finding is especially concerning given that the number of alters in DID patients is correlated with a significantly longer time to “fusion”: the integration of alters into a single personality, which is ostensibly the goal of treatment (Coons, 1984).

Many contemporary scholars regard DID as a disorder of belief: Individuals with this condition become convinced that they harbor multiple indwelling identities and act on this presumption (Lilienfeld & Lynn, 2014; McHugh, 2013). If these scholars are correct, alter reification methods will presumably only reinforce these erroneous beliefs and prolong treatment unnecessarily.

Harmful Psychotherapies versus Harmful Psychotherapists

A legitimate criticism of much of the previous writing on harmful psychological treatments (e.g., Lilienfeld, 2007) is that it has focused primarily on potentially iatrogenic techniques rather than on potentially iatrogenic therapists or therapeutic variables (Jarrett, 2008). An analogy to the literature on specific versus nonspecific factors in effective psychotherapy may be helpful here. Most research suggests that the lion’s share of the variance in therapeutic outcomes is attributable to nonspecific factors, such as the therapeutic alliance, therapist genuineness, and positive treatment expectancies (Messer & Wampold, 2002), although specific factors account for nontrivial amounts of variance as well (Lilienfeld, 2014). Similarly, nonspecific therapeutic influences, some of which may reflect largely stable styles among certain therapists, may account for more variance in negative treatment outcomes than do specific influences attributable to specific therapeutic modalities.

Much of the research literature on nonspecific negative therapeutic effects is preliminary, but it offers fruitful clues for further research. For example, research on psychodynamic therapy suggests that therapist interpretations, especially negative transference interpretations in response to clients’ frustration with the progress of treatment, are associated with ruptures in the therapeutic alliance and poorer therapeutic outcomes. In addition, studies of cognitive-behavioral therapy suggest that therapists’ repeated and rigid insistence on using certain techniques in spite of client protestations may be linked to poor outcomes (Castonguay, Boswell, Constantino, Goldfried, & Hill, 2010). Similarly, several findings suggest that subtle hostility on the part of therapists is associated with greater self-blaming on the part of clients and poor treatment outcomes (e.g., Henry, Schacht, & Strupp, 1990), although it is unclear whether such hostility causes such outcomes (for example, more argumentative clients may both elicit more hostility from therapists and be marked by a poor prognosis). Although drawn from diverse bodies of literature and correlational in nature, all of these findings raise the possibility that therapists who consistently blame their clients or dismiss their clients’ concerns are more likely than other therapists to generate negative outcomes.

Classic research by Yalom and Lieberman (1971; see also Hartley, Roback, & Abramowitz, 1976) on “casualties” in therapeutic encounter groups suggests that individuals who experienced markedly negative psychological sequelae (approximately 10% of Yalom and Lieberman’s sample) in these groups were more likely to have been exposed to leaders who were charismatic yet highly confrontational, challenging, and intrusive. Similarly, experimental research by William Miller and his colleagues on the treatment of problem drinkers indicates that therapists who adopt a directive and confrontational style are more likely to induce resistance in their clients and to produce poorer client outcomes than do therapists who adopt a supportive style (e.g., Miller, Benefield, & Tonigan, 1993).

On balance, research on therapist factors points to a dismissive, confrontational, and interpersonally aggressive style as linked to poor outcomes. The clients of therapists who consistently adopt such styles may tend to feel belittled and to feel that their concerns are being ignored or minimized. Nevertheless, because much of the research on adverse therapeutic variables is correlational, it does not allow for causal inferences. For example, it is not known whether negative therapist behaviors, such as an overbearing or arrogant interpersonal style, stems from, rather than generates, problematic client behaviors. Research using randomized controlled designs, in which clinicians are asked to adopt different therapeutic styles, could in principle address these questions, although such research may raise challenging ethical concerns regarding potential client deterioration.

Future Directions

The literature on the potential harmful effects of psychotherapy lends itself to several profitable future directions. The first is the development of more systematic means of identifying and monitoring harmful effects in therapy. For example, one easily implemented solution is to ask clients to complete a standardized inventory of their current signs and symptoms prior to each therapy session (Dimidjian & Hollon, 2010). Doing so would allow clinicians to track clients’ trajectories in treatment and more accurately detect deterioration effects. Such tracking is especially important in light of findings discussed earlier that many therapists markedly underestimate the proportion of their clients who are deteriorating (Walfish, McAlister, O’Donnell, & Lambert, 2012). Moreover, meta-analytic data suggest that the regular provision of ongoing client outcomes to psychotherapists enhances therapeutic outcomes and reduces the likelihood of deterioration effects (Lambert et al., 2003). An alternative approach, which is not mutually exclusive with the approach of systematically tracking client outcomes, is to encourage therapists to complete standardized checklists of potential negative events that arise during therapy. For example, Linden (2013, p. 293) constructed a broad checklist of such “unwanted events,” at least some of which may be produced by treatment. Among them are symptomatic deterioration, emergence of novel symptoms, family conflicts, work conflicts, and client noncompliance. Linden’s checklist may be worth administering in future psychotherapy process and outcome research.

Second, little is known regarding the potential therapeutic ingredients that contribute to iatrogenic effects (Bootzin & Bailey, 2005). It is plausible that such effects stem from a relatively small number of shared therapeutic mechanisms. For example, one key ingredient shared by CISD and other “cathartic” therapies is the tendency to unleash powerful negative emotions without affording clients effective skills for coping with them. Some of these methods, such as CISD and suggestive techniques for eliciting alters in patients suspected of having DID, also implicit “prescribe” clients’ likely symptoms, inducing in them expectancies regarding what thoughts and emotions to experience and behaviors to display. Still other techniques, such as Scared Straight and boot camp interventions, may exert negative effects by inducing resentment, providing inadvertent role models for negative behavior, or both. Nevertheless, because all of these hypotheses are speculative, further research on potential shared mechanisms for iatrogenic effects is sorely needed.

Third and finally, considerably more research is needed on the causes and predictors of client dropout. Data suggest that approximately 47% of clients on average terminate therapy on their own (Lampropoulos, 2011). Although a minority of these terminations probably arise from clients who are improving and no longer perceive themselves as requiring treatment, the substantial majority stem from clients who are either not improving or deteriorating (Tehrani, Krussel, Borg, & Munk-Jørgensen, 1996). To achieve a comprehensive understanding of client deterioration effects, researchers will need to learn more about the therapeutic experiences of the “silent plurality” of clients who choose unilaterally elect to leave treatment.

Further Reading

Barlow, D. H. (2010). Negative effects from psychological treatments: a perspective. American Psychologist, 65, 13–20.Find this resource:

Boisvert, C. (2003). Negative effects in psychotherapy: Research findings and clinical implications. Directions in Clinical and Counseling Psychology, 15, 37–48.Find this resource:

Bootzin, R. R., & Bailey, E. T. (2005). Understanding placebo, nocebo, and iatrogenic treatment effects. Journal of Clinical Psychology, 61, 871–880.Find this resource:

Castonguay, L. G., Boswell, J. F., Constantino, M. J., Goldfried, M. R., & Hill, C. E. (2010). Training implications of harmful effects of psychological treatments. American Psychologist, 65, 34–49.Find this resource:

Dimidjian, S., & Hollon, S. D. (2010). How would we know if psychotherapy were harmful? American Psychologist, 65, 21–33.Find this resource:

Jarrett, C. (2008). When therapy causes harm. The Psychologist, 21, 10–12.Find this resource:

Lilienfeld, S. O. (2007). Psychological treatments that cause harm. Perspectives on Psychological Science, 2, 53–70.Find this resource:

Lilienfeld, S. O., Lynn, S. J., & Lohr, J. M. (Eds.). (2014), Science and pseudoscience in clinical psychology (2d ed.). New York: Guilford Press.Find this resource:

Mohr, D. C. (1995). Negative outcome in psychotherapy: A critical review. Clinical Psychology: Science and Practice, 2, 1–27.Find this resource:

Rhule, D.M. (2005). Take care to do no harm: Harmful interventions for youth problem behavior. Professional Psychology: Research and Practice, 36, 618–625.Find this resource:


Adler, A. B., Litz, B. T., Castro, C. A., Suvak, M., Thomas, J. L., Burrell, L., … & Bliese, P. D. (2008). A group randomized trial of critical incident stress debriefing provided to US peacekeepers. Journal of Traumatic Stress, 21, 253–263.Find this resource:

Ammirati, R., & Lilienfeld, S. O. (2015). Forget psychological science: Israeli Supreme Court upholds conviction based on recovered memories. Skeptical Inquirer, 9, 11.Find this resource:

Barlow, D. H. (2010). Negative effects from psychological treatments: A perspective. American Psychologist, 65, 13–20.Find this resource:

Beck, J. G., Stanley, M. A., Baldwin, L. E., Deagle, E. A., & Averill, P. M. (1994). Comparison of cognitive therapy and relaxation training for panic disorder. Journal of Consulting and Clinical Psychology, 62, 818–824.Find this resource:

Bergin, A. E. (1966). Some implications of psychotherapy research for therapeutic practice. Journal of Abnormal Psychology, 71, 235–246.Find this resource:

Berk, M., & Parker, G. (2009). The elephant on the couch: Side-effects of psychotherapy. Australian and New Zealand Journal of Psychiatry, 43, 787–794.Find this resource:

Biklen, D. (1990). Communication unbound: Autism and praxis. Harvard Educational Review, 60, 291–314.Find this resource:

Bisson, J. L., Jenkins, P. L., Alexander, J., & Bannister, C. (1997). A randomized controlled trial of psychological debriefing for victims of acute harm. British Journal of Psychiatry, 171, 78–81.Find this resource:

Boisvert, C. (2003). Negative effects in psychotherapy: Research findings and clinical implications. Directions in Clinical and Counseling Psychology, 15, 37–48.Find this resource:

Boisvert, C. M., & Faust, D. (2006). Practicing psychologists’ knowledge of general psychotherapy research findings: Implications for science–practice relations. Professional Psychology: Research and Practice, 37, 708–716.Find this resource:

Bootzin, R. R., & Bailey, E. T. (2005). Understanding placebo, nocebo, and iatrogenic treatment effects. Journal of Clinical Psychology, 61, 871–880.Find this resource:

Bottcher, J., & Ezell, M. E. (2005). Examining the effectiveness of boot camps: A randomized experiment with a long-term follow-up. Journal of Research in Crime and Delinquency, 42, 309–322.Find this resource:

Bystedt, S., Rozental, A., Andersson, G., Boettcher, J., & Carlbring, P. (2014). Clinicians’ perspectives on negative effects of psychological treatments. Cognitive Behaviour Therapy, 43, 319–331.Find this resource:

Castonguay, L. G., Boswell, J. F., Constantino, M. J., Goldfried, M. R., & Hill, C. E. (2010). Training implications of harmful effects of psychological treatments. American Psychologist, 65, 34–49.Find this resource:

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