Can Therapy Be Harmful?

When you pick up a bottle of medicine at the pharmacy, or even grab something over the counter, you expect to see a little booklet come along with it. If you take the time to read it, you learn the proper dose and frequency, who should avoid the medicine, and all about its potential side effects, overdose risks, and potential interactions with other drugs. We implicitly understand that drugs that have the power to cure us can also do harm. Treatments that are powerful enough to heal inevitably have risks. The same is true for counseling and psychotherapy. For all that therapy offers, we do ourselves a disservice by ignoring the potential for harm.

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Research about the harmful effects of therapy is insufficient, but it does exist (e.g., Parry, Crawford, & Duggan, 2016; Boisvert & Faust, 2002; Berk & Parker, 2009). Since some of the benefits of therapy come from the positive expectancy that it will help, therapists don’t like to publicize potential downsides or risks. Further, the media seems to be biased in favor of psychotherapy these days. While this is good for destigmatizing the need for mental health care, it also means that research about its potentially adverse effects tends not to get picked up and distributed broadly.

One type of harm that has been researched is called iatrogenic harm. This is a fancy word from the field of medicine to describe the inadvertent harmful effects of diagnostic or treatment interventions. A good example in medicine might be the nausea, hair loss, and other effects of chemotherapy.

There are a number of factors that might lead to harmful therapy. One editorial by Parry, Crawford, and Duggan (2016) enumerated several. They suggested we consider the risks of the intervention itself. For example, a person may learn relaxation skills with their therapist but then misapply this tool in daily life as a way to avoid the routine and necessary stressors of life. A diagnostic assessment might lead a person to receive a diagnosis that is painful to learn, or even later discovered to be inaccurate.

The therapist themselves may also be a source of harm for their clients. The therapist might make an error in providing treatment, e.g., teaching coping skills in a way that is misleading or inaccurate. A therapist might hold certain biases or assumptions and impose those on the client. While there are times where therapists knowingly exploit or harm their patients, such cases are thankfully quite rare. What is more common is for well-intended therapists to inadvertently cause harm without even realizing it.

This article also highlighted the potentially painful interactions between therapist and client. For example, a therapist might attempt to use a motivational intervention with a client only to induce feelings of shame or make the client feel criticized for their difficulties. The therapist may lack the needed skill or expertise to notice and repair the damage caused in such moments, further worsening and complicating the harm.

There may not be a good stylistic fit between the therapist and client. For example, a therapist who tends to use humor might inadvertently hurt an earnest or sensitive client who feels the therapist’s lighthearted approach is minimizing their suffering. A poor match could also occur when a skillful therapist ends up seeing a client outside their area of expertise. The interventions that are helpful with one set of clients may be counterproductive or even harmful with others, leading to unintentional harm by even well-intentioned and usually competent therapists.

Parry and colleagues (2016) also discussed risks that arise from what the client brings to the interaction. For example, a client can become dependent on their therapist and develop difficulties making autonomous decisions between sessions because they want to run everything by the therapist first. Some clients may have been taught to hide their emotions or to never criticize authority figures, which makes it more difficult for therapists to receive important feedback or to read what is happening emotionally in the moment.

Another area highlighted in this article were the systemic factors that might lead to harm. For instance, a health care system might require therapists to have caseloads that a too large to give adequate time and attention to each client. Systems may also lack clinicians with the expertise needed to appropriately serve their clients. If trauma or substance abuse are common, but clinicians do not have the specialized expertise needed to address such challenges, then the situation is ripe for harm.

The good news is that negative effects from psychotherapy are thought to be relatively rare, with estimated rates typically around 5% (Parry, Crawford, & Duggan, 2016). Nonetheless, as therapists, clients, and caring loved ones of people in therapy, we cannot forget that such risks do exist. There may not be a little paper booklet that comes with every therapy session, but just like other medical treatments, we should be on the lookout for potential adverse effects. The sooner we are aware of them, the sooner we can take action to alleviate them. Even better, with more research in this area, the mental health field can come to understand harm better and reduce the likelihood of it happening in the first place.

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