4 ways therapy can do harm and why that is good news.

My former supervisor and teacher, Sylvia, used to tell me, "If you are stuck with a client, you need to put that on the table.  If you and the client can't get unstuck, stop the therapy."  I have been thinking about what great advice that is and how hard it can be to follow.  Clients will often say to me, "More therapy can't hurt, right?"  I even hear that from medical professionals and sometimes mental health professionals.  Generally, people know that insulin can hurt, and they don't take it just 'cause.  People don't undertake minor surgery for no reason.  Aspirin if taken improperly can put a person in grave danger.  If a therapy is capable of affecting someone's well-being for good, then it can also do harm if administered when it isn't indicated or in ways that aren't indicated.  Stated another way; If it can't do any harm then it is not worth doing.  I am not talking about an abusive or incompetent therapist or an unproven therapy.  I am talking about how psychotherapy can hurt when administered properly for the wrong situation or in the wrong dosage.

1. Psychotherapy directed towards a fundamentally well person in a bad situation can make the person feel responsible for his or her situation and aggravate worry.

This one happens with kids a lot.  The parents come into a therapist's office and say, "My kid is anxious/sad/angry all the time.  We don't want to discuss our fighting/grief/parenting.  Work with the kid."  The therapist can treat the kid using behavioral techniques for tackling whatever his/her symptoms might be.  I have heard therapists say, "At least I can offer the kid tools for dealing with X that may alleviate one difficulty in a difficult life."  I don't agree with this.  I think treating that kid in isolation gives the parents license to continue their behaviour and can put the spotlight on the child whose symptom is really the family's.  This may exacerbate feelings of responsibility for the family's difficulties.

2. Therapy that doesn't change the music.

This one happens with couples often.  Couples will come into therapy and insist on having the same arguments that they have at home.  I often say to them, "It's okay to fight in therapy, but I want you to at least have a different fight than you have at home."  Therapy is about making change in patterns and if you are doing the same thing in therapy that you are doing at home, you aren't changing a pattern, you are rehearsing it and you may be reinforcing it.   Some couples can't stop this, which is painful for therapists and the clients, but rather than have a bad experience of therapy and a lot of extra practice doing what hurts, it is better to stop therapy.  The couple may be able to come back when they are in a different place or work with a different therapist who can get them pointed in a different direction. 

3. Psychotherapy in place of something else that would give more well-being.

People are busy.  Therapies can be expensive.  People may prioritize psychotherapy over other things, either other therapies or other activities that could improve their well-being.  People are often choosing between therapy and a gym membership or a babysitter or a speech therapist or a soccer practice.  Those can sometimes be false choices but I actually think that more often than not, they are real.  I am all in favour of people prioritizing their mental health and their close relationships but the best expression of wellness is living a full life, not being in therapy.  Sometimes people believe, mistakenly, that because they are in therapy, they are taking care of their well-being when, in fact, they are using therapy as a smoke screen.  A good question for clients and therapists is "If the client wasn't here, where would s/he/they be?  What does missing X mean?"

4. Ending too early.

The pioneer of systemic, family therapy, Salvador Minuchin pointed out that sometimes people try something new to make a change but stop early when they see no benefit.  Some changes yield benefit in a one-to-one ratio -- a straight ascending line -- but sometimes change comes more as an exponential curve or even a "hockey stick" curve in which a person sees little benefit at first but experiences big pay-offs when s/he persists.  The down-side of ending early is that it can feel disheartening to work at something and see no result.  Depressed people often cognitively distort failures so that is all they see and they see those failures magnified.  If a depressed person tries cognitive behavioural techniques in therapy, for example, and doesn't experience change fast enough s/he can view it as yet another failure and feel worse.  Going back to the surgery analogy, if we abandon surgery in the middle the results will be not only a return to pre-surgery function but worse functioning. 

Avoiding these pitfalls is part of providing good therapy just as providing good medical care involves more than just prescribing medication, but knowing when and where to prescribe and when not to.  All this isn't meant to scare people off therapy, but rather to point out that therapy has real effects.  If a therapy isn't working, feels like it is hurting more than it is helping or feels stuck, take the time to look at that, client and therapist together.