Can Psychotherapy Cause Harm?

Can psychotherapy cause harm? When does it become harmful for clients? These are rarely examined questions, and no ethical psychotherapist or counsellor sets out to cause harm in practice. However, it can happen. This article summarises our training workshop with Dr Phil Mollon, who faced this issue head on for us and asked who was brave enough to question their own practice.

Causing harm through psychotherapy

When we talk of harm its easy to imagine gross misdemeanours, and yet harm which arises when therapy is practiced ‘well’ (meeting all guidelines) can cause just as much damage to the client. Essentially this occurs when the client experiences your good intentions as damaging in some way.

Dr Mollon looked at this issue of harm in psychotherapy from a number of different angles, gave examples of harmful therapy from his career, as well as asking the question of why this important issue isn’t more widely discussed. Why is it never openly stated that therapy can not only be lacking in efficacy, but can even exacerbate clients presenting issues?

Examining when psychotherapy can be unintentionally harmful is a topic that takes some courage to tackle, but it’s important to do so in order to avoid such a problem with future clients.

The client’s view of therapy

There are obvious ways in which therapy can become perverted in the service of destructiveness towards the client – making hurtful interpretations, aggressively imposing a theory on the client or being disparaging of other resources the client may seek which the therapist does not favour. But these are not the focus of this investigation.

We often think that what we as therapists try to offer is in the best interests of the client. But do we think about how the client might view things differently? Here are a few common scenarios where the client’s perception of the therapy process may be different to that of the therapist.

  • The long-term client – A client in long term therapy may feel stuck or that they are no longer progressing. They might think about leaving therapy and talk about this with their therapist. The therapist could react in a number of ways which could be helpful, but what if they believe so stringently in what they are doing that they can’t see the client’s point of view? Telling the client that ending therapy would be a defensive escape from a difficult issue arisen in therapy might dismiss the lived experience of the client in the room and make them feel unheard and ignored, creating resentment in the therapeutic relationship.
  • The misunderstood CBT process – CBT therapy can be incredibly useful in helping clients to manage their experiences and emotions, but it can often be missold as a ‘cure’. Take, for example, a traumatised client who is taught anxiety management by their CBT therapist who spends no time addressing the trauma itself. As time passes and the client begins to re-experience the trauma, they may feel they have failed, thus experiencing harmful effects from a treatment that was promised to end their suffering.
  • The excessive treatment – Imagine a psychoanalyst whose training has taught them that analysis 5 times a week is the only approach that works, they’ve experienced it themselves and seen the benefits and so believe it to be true. But to the client this could seem excessive, as invasive in their life, as all pervasive with no escape and potentially financially damaging.
  • Reemerging trauma – Clients with a past experience of trauma might attend therapy in order to resolve feelings about it. The therapist, in order to understand the experience or wanting to work through it may address that topic in session, but in talking about that experience the client may in turn feel re-traumatised by a therapist with no understanding of their current needs.

None of these examples (and there are many more) are intentionally harmful, and yet we can see that from the point of view of the client, where they have sought help from a trained professional in order to feel better, they could have left the experience feeling worse.

Research into unintentionally harmful psychotherapy

There is very little research into the harm that properly executed therapy can cause. This is an unusual anomaly for a medical field, as in every other area research is abundant into both efficacy and failure of all treatment options. However, sparse though it may be, the research does exist and it indicates that psychotherapy is often not very effective in alleviating distress, and can leave some clients in a worse state.

Harmful side effects from psychotherapy

In their 2009 paper, The elephant on the couch – side effects of psychotherapy, Berk & Parker raise a few interesting points.

Loss of autonomy

Firstly, although the idea of clients developing an internalised therapist is often seen as a positive outcome of therapy, they posit that “The longer any patient attends a psychotherapist, irrespective of how therapeutic the therapy, the patient risks contracting their independent capacity to make decisions (self-mastery)… distanced from the capacity and risks inherent in making their own mistakes in the real world, and more importantly learning from them”. There is, of course, no malice intended in this interaction, and indeed a client proudly proclaiming ‘I asked myself what you would say’ can be seen by the therapist as a positive sign of the client taking time to examine their actions outside of the therapy session, and yet on being shown the flip side of the coin we see that it too is equally valid. (Australian and New Zealand Journal of Psychiatry 2009;43:787-794)

Reliance on negative coping strategies

The process of therapy can also be taxing on the emotional resources of the client. If a client has unhealthy coping strategies for negative or stressful situations such as substance misuse or disordered eating, then by engaging in therapy they might find themselves overwhelmed, and turning to these behaviours in order to comfort themselves to cope with what therapy has brought up for them. (Dishion TJ, McCord J, Poulin F. When interventions harm. Peer groups and problem behaviour. Am Psychol 1999;54:755-764)

The end of therapy

It is also important to note that even in therapy where no harm has been experienced by the client, there can harmful outcomes when it ends: “Over time, long-term bonds of attachment to the therapist make termination of therapy a traumatic life event, particularly if transference has been an important therapeutic component.” (Berk, Parker. The elephant on the couch – side effects of psychotherapy. Australian and New Zealand Journal of Psychiatry 2009;43:787-794)

The statistics on therapy’s success

The dismaying truth about psychotherapy is that sometimes it just isn’t very effective despite the therapists best intentions and extensive training. Overall, outcome research gives quite pessimistic results, suggesting that only 60% of clients benefit from therapy, and 15-24% of adolescents leave therapy in a worse state than when they started (Lambert).

The danger of therapeutic goals

Setting goals is a great way to structure the therapeutic relationship, but whilst the overall goal of therapy is to reduce internal obstacles to wellness, some goals may implicitly promise illusions that cannot be fulfilled.

Setting goals and targets in therapy can seem like a good idea, but it’s important to be conscious of the kind of targets that are set.

Goals, although a great way to set a target to work towards, can cause harm to clients who experience feelings of failure. There is a danger that they may feel internal or external blame “for not meeting intervention targets, have been held to increase helplessness and self-blame, and so undermine self-efficacy”. (Marlatt GA, Gordon JR. Relapse prevention: maintenance strategies in the treatment of addictive behaviours. New York, NY: Guildford Press 1985)

Goals to avoid in therapy

Illegitimate goals for therapy (those that could be said to cause harm) might include illusory formulas for happiness, forcing the therapist’s world view onto the client or selling the idea of the therapist knowing best. Legitimate goals of therapy should therefore be client-led – to help the client resolve what they deem to be internal obstacles to achieving goals and satisfying desires in relationships and work, and to help counter unrealistic illusions about what life should be. Therefore goals should be helping to facilitate a shift from neurotic misery to ordinary unhappiness, to paraphrase Freud.

Avoiding harm in psychotherapy

So, the research shows that unintentional harm in psychotherapy is a very real possibility. What steps can we take to mitigate this?

Accept that psychotherapy can be harmful

If we as professionals can accept the unpalatable truth that we may cause harm to our clients, then we can take steps to minimise that harm.

“However painful it may be, it is important for those of us who are psychotherapists to recognize that we have all likely harmed one or more of our clients… we would venture to guess that all experienced psychotherapists have, at one point or another in their careers, failed to meet the most basic and ethically important principal guiding the profession: First, do no harm.” (Castonguay et al. 2010. Training Implications of Harmful effects of psychological treatments. American Psychologist, 65(1), 34-49)

Seek feedback from your client

With acceptance comes the ability to minimise harm. So how do we go about this? We have seen that the most common method of harm is to impose upon the client, and so feedback must be a key component of a positive therapeutic relationship. Regularly reviewing the work, checking goals and simply asking ‘am I helping’ can make a lot of difference to a client – offering them power in an unbalanced relationship and control over their treatment.

Maintain flexibility in therapy

Effective treatment will likely not have a singular focus but will balance an exploration of the traumatic past with an intention for a positive future and methods to explore obstacles and amend as necessary. It will be flexible and client-led, and will be open to acknowledgment of the therapist’s imperfection.

Understand the therapeutic role in the relationship

Therapists carry a heavy burden, an expectancy for them to ‘fix’ the unfixable, but with this comes an assumption that we can fix everyone, and that it is our job to fix. In reality therapy is about becoming a fellow traveller – taking part of the client’s journey with them and helping them to explore and understand their world for themselves. We might get it wrong, but we are human, and in owning our mistakes we can perhaps avert harm, and provide a lesson instead.

Often it is what the therapist does not do that is most important – does not presume to know, does not try to fit the client into a theory or dogma, does not assume the position of authority. By balancing this negative capability with active enquiry and appropriate concern we might just minimise our potential to harm the client enough to help them to grow.

Are you interested in learning about working with shame in therapy? Join our online CPD workshop on March 4th, 2023: Why Shame Matters: Relational Perspectives on Working With Shame.

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  1. jenny shepherd on 2017-10-12 at 5:04 PM

    Really helpful to have this summary of that CPD which I had every intention of going to but was away on the date. I have often wondered why there is not more information/research about the harm that can be done as there are always two sides to everything. If this CPD is repeated or another one like it, please keep me informed!

    • Brighton Therapy Partnership on 2017-10-14 at 5:01 PM

      Thanks for your comment Jenny. Are you on our mailing list? You’ll get to find out about all the CPD we offer straight to your inbox if you are!

  2. Steve Newton on 2017-10-20 at 3:09 PM

    These are all important points and legitimate concerns but all these type of scenarios should (oh no, I said should) have been well covered and discussed as part of any decent training programme. Plus, at least some of them should be picked up and addressed in supervision. But with all the safeguards and safety nets, there’s always something that could slip through. That fact alone makes this article well worth its salt and there’s never any harm in being reminded of the potential pitfalls of therapeutic work.

  3. Phil on 2017-11-06 at 12:28 AM

    Hi Steve, was the issue of harmful therapy covered on any training/s you’ve attended? I ask as my research around the topic found that the issue of harmful therapy is rarely, if ever, directly a part of trainings. What is mentioned are gross issues of harmful therapy, such as sex with clients – yet that type of harm wasn’t Phil Mollen’s presentation – he covered harm that occurs within the codes of ethics and so is more subtle and often goes unexplored. When we look for the terms in core texts books they are rarely present. This suggests the topic of harmful therapy is under-explored and under-reported, which is why Phil Mollen’s presentation is so important. Be curious to hear your thoughts. Phil (not Mollen!).

  4. Roslyn Byfield on 2017-12-19 at 9:29 AM

    I think you should include lack of a clinical will (still quite common), with clients being disturbed, some very seriously, if they turn up and find there therapist has been incapacitated or died and no one let them know or supported them. BACP doesn’t even yet have clinical wills in its Ethical Framework though other professional bodies mandate them. This is still an underrecognised area.

  5. Christine Bonsmann on 2018-01-17 at 9:59 AM

    This is an interesting and highly relevant article for the profession. Research does exist to demonstrate that therapy can be harmful. Sadly much is unpublished. The agenda of therapy professionals and possibly journal peer reviewers may be to stick to the narrative that ‘therapy works’. The learning for all of us comes from understanding clients’ experiences in depth and not pathologising clients who experience therapy as harmful.

  6. Martin on 2018-02-24 at 1:38 AM

    What I don’t see anywhere on this list is communicating to potential clients that therapy can be harmful. It should be included in initial and ongoing consent processes. I find this rarely to be the case, and when it is, it is couched in language in language about how people in your life may not like the growth you experience in therapy.

    Therapists should believe therapy is potent. While ideally helpful, sometimes it is not. Clients should be aware of this while making a decision to engage or continue to engage in therapy. Having this known from the beginning of therapy may help a therapist and client mitigate harm if it occurs or better transition out of harmful therapy. It helps clients not feel blamed or feel like they failed or not engage in help seeking behaviors in the future.

    I can’t think of other intensive, expensive medical experiences where it is ok to not include the quite substantial risk for harm a minority of therapy clients will experience when they engage in therapy.

    • ANDREW STEWART on 2023-04-25 at 9:00 PM

      I totally agree. In my view it is unethical. Side stepping questions at the start denies the opportunity for informed consent and sets up the experience to be lacking in trust, filled with anxiety and risk.

  7. Gina C Weydahl on 2018-06-03 at 10:45 PM

    Thank you so much for this article. So glad that someone is talking abouth this issues. Helps me a lot in ending my therapy that was more than good for three years but led to depency on to a therapist who stated when I said I know was able to stand on my feet , and gave him a lot of the credit then he said to me : this is a dangerous position because now you are not open. In this litle room with a professonell therapist this and other similar statement was dangerous to me.
    I manage to leave and both love and sometimes hate him. Able to bear the opposites. 🙂 But therapy can be really dangerous.

  8. Charlotte on 2019-04-08 at 5:00 PM

    I’m so relieved to read this article. I underwent CBT in the NHS for OCD. My therapist did some things really well but the way he handled me personally towards the end of therapy left me profoundly traumatised and so depressed that I was suicidal for a while and had well developed plans to hurt myself.
    I did try to resolve things with him but it went disastrously wrong. I admit that I wasn’t direct enough in letting him know how much he had hurt me and I regret that very much. I didn’t follow it up further with the NHS as the things he did weren’t ‘big things’, just a culmination of smaller events that left me feeling misunderstood, judged and completely worthless.
    Four years later, after a lot of (private therapy), strong medication and two years not working I am finally starting to feel a bit better but therapy will always be one of the worst experiences I’ve ever been through. Nothing else has come close to the pain of feeling so brutally irrelevant to someone I trusted and told all my innermost thoughts to.
    As a result I’m passionate about anything that raises awareness of this issue. If anyone is researching this and needs a case study please contact me; I’d be very willing.

    • Karen on 2020-11-04 at 1:39 PM

      Hi Charlotte

      I had counseling sessions for which in the end left me with flashbacks and having to deal with my own triggers for certain issues I had not really talked about before. I was not aware of the true affects of triggers and has taken me a long time to understand them. something the counselor did not discuss or approach me with, even when I tried to speak up. I have felt overwhelmed with having to cope and deal with what to others could seem over dramatic and misunderstood. Counsellors should always talk of how counselling can be a support yet also there can be issues of triggering, re traumatising. I kept wondering why I would go back to the counselling, for it was there I opened up too quickly and where I had nowhere to process what was coming out of me and somewhere which felt a safe environment. It is wonderful you are now healing yourself and helping others, and to know that now with mental health being more so out there, we must address that , if we choose to, finding the proper, trained support for our own personal issues is so important. There can be people who open up only to feel at fault for the very issues they are trying to address, validate and find clarity, understanding. It should be completely trained that all counselling, therapy speak first of the implications that can arise in sessions so the client is aware. This in itself is empowering the client and shows that the counselor, therapist is also aware that things will and can come up for a person that will overwhelm, re traumatise and may, will need tentative and compassionate support, support that does shame nor is vague, or neglectful. Best wishes Karen

    • Gina Weydahl on 2022-05-01 at 9:34 PM

      ….but therapy will always be one of the worst experiences I’ve ever been through. Nothing else has come close to the pain of feeling so brutally irrelevant to someone I trusted and told all my innermost thoughts to.

      I just agree so deply. The harmed it caused me – went back to sort out things, is beyond anything.

  9. Karen on 2020-11-04 at 1:41 PM

    Apologies meant does not shame a client.

  10. Anita on 2020-11-25 at 12:10 AM

    I have a question, how does one heal from harm caused by therapy? A lot of the “treatment” I’ve had has been highly damaging – I’m kept awake at night by flashbacks. I’ve found that I cannot trust any more therapists as most of them (all that I’ve tried) think like Steve Newton’s comment and dismiss/ignore said harm I experienced. I’ve realized that I cannot expect healing from a field that cannot admit its own issues. But honestly, I don’t know how to cope with all these new triggers, breakdowns, nightmares and flashbacks.

    • Eve on 2020-12-08 at 4:13 PM

      Hi, I’m really sorry you are going through that. I have been dealing with the same issue from a previous therapeutic relationship – flashbacks, triggers, constant ruminating about it, and rage. I also struggled with lots and lots of shame, and the belief that something was inherently wrong with me and that I was creating this for myself.

      It sounds counter-intuitive, but I am working on it with a new therapist that I trust. This is not to say that your fear and your reluctance are not understandable – you have every reason to protect yourself from the very people who hurt you. But what I realised was that this was just going to get worse over time. I spent a year before seeking help again, and even though I thought I could make amends with it on my own and eventually move on, I did not.

      My therapist is very understanding about it. She was the first to suggest that what I experience is a traumatic response and she treats it as such. This was weird for me because I certainly did not treat it as a trauma but as a weird and shameful obsession, a scary part of myself that I had to hide. In the end, it is healing to be validated by an authority figure who’s similar to the one who hurt you, if you can find one to trust.

      I see it sort of like women who were abused by men and then get into a therapeutic relationship with a male clinician, even though they are terrified of even being in the same room with a man. It is tricky but if done right, and if a healthy, safe and trusting relationship emerges, it can be healing on its own.

      Again, I am not undermining your concerns. What you are going through is not easy, and what worked for me will not necessarily work for you. I just wanted to say that you are not alone, and your experience is 100% valid. It is hard to experience something so intensely that no one in your immediate circle understands. You deserve all the help (professional or not) you can get.

      • Anita on 2020-12-16 at 11:44 PM

        I originally tried to trust another therapist after that experience. However that therapist turned out to be exactly like my previous one. And all of the other therapists I saw have no way to tell if they are actually doing harm. Nor do they know how their methods of choice could cause harm without blaming the client. I want to heal but given my experiences, I’ll likely have to figure out stuff on my own.

        For me, it was like women who were abused by men and then get into a therapeutic relationship with a male clinician, even though they are terrified of even being in the same room with a man. But this time, said clinician doesn’t believe spousal abuse exists, blames her for “not trying hard enough/many times” and refuses to learn about the signs of abuse.

        Getting a therapist who understands that is kinda like winning the lottery. It’s nice if that happens but odds are you’ll go broke if you make it part of your plan

      • Gina Weydahl on 2022-05-01 at 9:43 PM

        Thank you, Eve-
        First I used a long time reading about different therapists . I found her on the basis of some of her comments in a paper and online. Then I intervjuet her 45 min abouth her thinking- and so on. First after that I started to talk regularily- take time finding the right one was a must !!

    • Gina Weydahl on 2022-05-01 at 9:37 PM

      The only way I know about is to “trust” yourself – try to be aware of thoughts and dreams- when you understand what has really happened to you there will be healing. I still heal after many years- I was more like in a sect- H messed with my head and that takes time to heal. All my love- Gina

  11. ANDREW STEWART on 2023-04-25 at 9:13 PM

    Five years after psychotherapy I still can feel angry and depressed. It was so demeaning to be pressured to continue when I had no trust. This is one of the best articles online about what is wrong with the field of psychotherapy. Trying to be heard and having your concerns dismissed is a mistake I struggle to forgive. It doesn’t help users of course that there is no willingness to learn from any of the experiences people have. It’s all brushed away with “therapy isn’t for everyone” or “it wasn’t the right time.” Mistakes happen. But burdening people with failure in a process that isn’t explained is unforgivable. It’s not a microcosm of life. It is the exercise of power over the weak. Good intentions don’t mean anything if the intention of therapists isn’t something clients can be informed of.

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