Psychological Treatments That Cause Harm

Esther12

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Open access: http://users.ipfw.edu/young/350-Abnormal/assignments/Psych-treatments-that-cause-harm.pdf

I only had a browse of this, and decided it was one of the many interesting papers I was going to have to put to one side, but thought that it could be of interest to someone else here (feel free to summarise for us!) so am posting it up.

Psychological Treatments That
Cause Harm
Scott O. Lilienfeld
Emory University
ABSTRACT—
The phrase primum non nocere (‘‘first, do no
harm’’) is a well-accepted credo of the medical and mental
health professions. Although emerging data indicate that
several psychological treatments may produce harm in
significant numbers of individuals, psychologists have
until recently paid little attention to the problem of haz-
ardous treatments. I critically evaluate and update earlier
conclusions regarding deterioration effects in psycho-
therapy, outline methodological obstacles standing in the
way of identifying potentially harmful therapies (PHTs),
provide a provisional list of PHTs, discuss the implications
of PHTs for clinical science and practice, and delineate
fruitful areas for further research on PHTs. A heightened
emphasis on PHTs should narrow the scientist–practi-
tioner gap and safeguard mental health consumers against
harm. Moreover, the literature on PHTs may provide in-
sight into underlying mechanisms of change that cut across
many domains of psychotherapy. The field of psychology
should prioritize its efforts toward identifying PHTs and
place greater emphasis on potentially dangerous than on
empirically supported therapies.
Some bits remind me of Dolphin 's comments comparing safety procedures for drugs and psychological treatments:

This state of relative neglect concerning harmful psycholog-
ical treatments contrasts sharply with the marked recent sci-
entific and media interest in the potential negative effects (e.g.,
suicidality) of psychotropic medications, particularly fluoxetine
(Prozac) and other selective serotonin reuptake inhibitors
(Sharp & Chapman, 2004). Psychology, of course, has no formal
equivalent of medicine’s Food and Drug Administration (FDA)
to conduct Phase I or Phase II trials, both of which help to
identify safety problems with novel treatments before they are
disseminated to the public. As a consequence, the systematic
monitoring of unsafe psychological interventions devolves
largely or entirely to the profession of psychology itself. I will
argue that because the field of psychology has been reluctant to
police itself (Meehl, 1993), the consequences for mental health
consumers and the profession at large have been problematic.
Because psychology lacks an FDA to ensure safety monitoring
and quality control of treatments, the profession at large must be
considerably more aggressive in self-policing and in confronting
the hazards posed by PHTs. In the recent past, the principal
impetus for constraining the use of some PHTs, particularly
recovered-memory techniques and DID-oriented therapy, has
come not from within the psychological profession but rather
from outside of it, in the form of widely publicized lawsuits
against practitioners (Lynn et al., 2003). Therefore, major pro-
fessional organizations in psychology should play a more active
role in educating clinicians regarding the hazards posed by
PHTs. Regrettably, training in some PHTs, including CISD and
rebirthing, has been eligible for continuing-education credit
from APA (Wood, Garb, Lilienfeld, & Nezworski, 2002).
It didn't look killer interesting, or to be making really startling new points with references to data that was important, but I may have missed stuff, and I didn't work to understand anything with unfamiliar terminology. Overall, it seemed pretty complacent, considering the topic, and the recognition of the importance of 'do no harm' in medicine.

 

lansbergen

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It does seem that some are trying to claim that expertly provided psych therapies should be respected because the harness the magical power of placebo.

Alternatively, those 'expert' homeopathy quacks should be treated with disdain, because their treatments are no more effective than placebo.
:D:D:D:D:D
 

A.B.

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There are studies which claim to show that psychotherapy is more effective than placebo.

However, one should not forget that not all placebos are created equal: sham surgery is a stronger placebo than a sugar pill.

Comparing psychotherapy with a sugar pill could merely be, for all we know, a comparison between two different placebos.

A better comparison would be real psychotherapy with sham psychotherapy with social interaction.
 

peggy-sue

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I find the whole idea very interesting.
I have a particular "downer" on CBT which I had long before I got ill - because of a course of CBT I had for OCD.
I was such a resounding success story that my therapist used my case for her PhD.:thumbsup:

I was not any sort of success story at all. She did not follow me up, she did not address the reason I had developed OCD in the first place.

She had decided my reward for cutting down the number of times I washed things, or washed my hands should be an alcoholic drink.
She clearly had not read OU lecturer Fred Toate's excellent book on OCD, which specifically warns against folk with OCD using alcohol to self-medicate.

I carried on after I had been "cured", with my new problem of abusing alcohol to hide from and cope with the real reason for my problems, which was bullying and mental abuse from my ex.

The entire case had been a waste of time.
A sticky plaster over a cancer.

But my therapist put a lovely spin on it.
 

user9876

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It does seem that some are trying to claim that expertly provided psych therapies should be respected because they harness the magical power of placebo.

Alternatively, those 'expert' homeopathy quacks should be treated with disdain, because their treatments are no more effective than placebo.

I think there is a research group looking at whether the placebo effect can be used to treat people. I think they are the ones who carried out an asthma study and come from a acupuncture background.

My feeling is that the placebo effect is about changing how people feel about illness and interpret things rather than having any underlying effect. Hence it seems to be effective with pain, it doesn't reduce pain just helps how people interpret or report their pain levels.

The dangers of such an approach is that people will ignore symptoms or do stuff that will harm their body. I've heard people say that homeopathy doesn't do any harm as long as people still follow conventional medical advice. However, I don't believe that this is the case where the placebo effect in homeopathy could cause symptom and pain level reports to be down played.
 

peggy-sue

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I would prefer to see the harms caused to all therapy clients, (given what happened to me), not just ME ones.

CBT is promoted over all other forms of psychotherapy because it is the cheapest and quickest.
It deliberately does not try to address the reasons for problems, it just fixes the immediate symptoms. The therapists stop at the point where they can say the behaviours are gone/ abated. That is deemed a cure.

But as far as I am concerned, if the reasons for the problems have not been addressed, they will just manifest in another way. In my case, it was alcoholism, encouraged with the blessing of a "therapist".
 

peggy-sue

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It was. But that's CBT for you.
Does not give a damn about any harm it might cause and deliberately does not look for any, just in case it finds it.

:zippit: The miracle of CBT cannot be questioned.:zippit:
 

Valentijn

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I would very much like to see good research studies on the harms done to ME/CFS patients by bad psychotherapy.
My case study would show that the Dutch version of CBT for ME/CFS made me feel seriously suicidal for a day or two.

The practitioner (psychologist) was trying to convince me that only I could "heal" myself, which I already knew was total bullshit. She insisted I imagine my symptoms failing to improve, and that doctors could not help me. So basically she repeatedly (like 5 or 6 times) had me visualize that in one session, which had me sobbing for most of the appointment.

It was incredibly painful. To imagine that nothing could be done about ANY of my symptoms, unless I could force myself to somehow make them disappear. I would also be in a lot of pain, very disabled, unable to sleep, constipated, brain-fogged, etc, etc, etc.

Her abuse was triggered by me wanting to talk about a very bad appointment with a neurologist in the process of getting my neurally mediated hypotension diagnosed. So instead of getting to vent about that abuse, I got more abuse and complete rejection of my experiences.

Fortunately I had my fiance with me, and he was very supportive. And immediately after the psychologist I had an appointment with the physiotherapist at the same clinic, who was a pretty nice guy. He could see how upset I was, and immediately went to have a talk with the psychologist, looking somewhat pissed off.

After a day or two, I was able to switch from being seriously suicidal to being seriously pissed off. I researched Dutch CBT-for-ME/CFS a bit, and realized where her abuse originated from. I also found out that they're strongly opposed to patients using any assistant devices, so my fiance and I kept going to appointments just to discuss mobility scooters as much as possible, and eventually give her credit for our decision to purchase one to follow her instructions to "get out more".

But without the support of my fiance and the physiotherapist, and the knowledge of how stupid and ill-informed she was, things might have turned out very differently. And I can easily imagine how it might turn out differently for someone with less support and self-confidence.

So now I just hate her and hope she suffers as much as we do. And I don't feel guilty about that at all.
 

peggy-sue

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Yet I read, just recently, on an official thingy from NICE recommendations about mobility scooters for "CFS/ME" - which said that these should NOT be given to sufferers because "they encourage laziness".
Same for Blue Badges for cars. Not to be given to PWME.

Edited to add:-

:D For this post, my 1,000th, I got awarded "Addicted" status here. Quite appropriate for me in this thread.

Valentijn, I'm so sorry to hear of what happened to you and very glad you had somebody with you at the time.
You do raise a very important point though, which has been noticed by Dolphin too
- about the psychological damage that can be created
by the situation of having a person in authority,
somebody on whose goodwill you depend upon for help,
sitting there telling you that you are doing this all to yourself on purpose, that you are not really ill at all, and refusing to recognise your reality as valid.
 

Dolphin

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My case study would show that the Dutch version of CBT for ME/CFS made me feel seriously suicidal for a day or two.

The practitioner (psychologist) was trying to convince me that only I could "heal" myself, which I already knew was total bullshit. She insisted I imagine my symptoms failing to improve, and that doctors could not help me. So basically she repeatedly (like 5 or 6 times) had me visualize that in one session, which had me sobbing for most of the appointment.

It was incredibly painful. To imagine that nothing could be done about ANY of my symptoms, unless I could force myself to somehow make them disappear. I would also be in a lot of pain, very disabled, unable to sleep, constipated, brain-fogged, etc, etc, etc.

Her abuse was triggered by me wanting to talk about a very bad appointment with a neurologist in the process of getting my neurally mediated hypotension diagnosed. So instead of getting to vent about that abuse, I got more abuse and complete rejection of my experiences.

Fortunately I had my fiance with me, and he was very supportive. And immediately after the psychologist I had an appointment with the physiotherapist at the same clinic, who was a pretty nice guy. He could see how upset I was, and immediately went to have a talk with the psychologist, looking somewhat pissed off.

After a day or two, I was able to switch from being seriously suicidal to being seriously pissed off. I researched Dutch CBT-for-ME/CFS a bit, and realized where her abuse originated from. I also found out that they're strongly opposed to patients using any assistant devices, so my fiance and I kept going to appointments just to discuss mobility scooters as much as possible, and eventually give her credit for our decision to purchase one to follow her instructions to "get out more".

But without the support of my fiance and the physiotherapist, and the knowledge of how stupid and ill-informed she was, things might have turned out very differently. And I can easily imagine how it might turn out differently for someone with less support and self-confidence.

So now I just hate her and hope she suffers as much as we do. And I don't feel guilty about that at all.
Very sorry to hear of your experiences, Valentijn.
Although I've looked into the physical problems that graded activity-oriented CBT/GET can cause, I haven't really looked in to psychological harms.
Also, it frustrates me when people say that CBT will help with coping. If it's graded activity-oriented CBT, some parts might, and some parts might have the opposite effect. :(
 

Esther12

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There are studies which claim to show that psychotherapy is more effective than placebo.

However, one should not forget that not all placebos are created equal: sham surgery is a stronger placebo than a sugar pill.

Comparing psychotherapy with a sugar pill could merely be, for all we know, a comparison between two different placebos.

A better comparison would be real psychotherapy with sham psychotherapy with social interaction.
It's really hard to control for 'worthless placebo' with talking therapies, as therapists can claim that the 'real' efficacy of their treatments stems from the aspects of treatment also likely to lead to response bias.

Without having done anything to improve patients health, it's easy to image being able to manipulate patients into reporting less symptoms by:

1) Presenting oneself as an authority figure with real power who is working to help improve symptoms
2) Being likeable, caring, and giving the impression of really trying to help
3) Encouraging the patient to believe that they have some control over their symptoms, and that patients who do as they're told will report improvement in symptoms (this could be aided by giving them a somewhat challenging task intended to aid improvement)
4) Encouraging patients to believe that thinking more 'positively' about symptoms is the correct thing to do, and will help them.
5) You get the drill, etc, etc.

Yet CBT promoters can claim that a 'placebo' intervention which included these things could be genuinely effective. (Sorry - really tired... going to stop this post rather bluntly - bleurgh).
 

Dolphin

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It's probably important to distinguish in discussions about psychotherapy between mainly biological conditions and mainly psychological conditions: if your mood for example is the main problem, an intervention like psychotherapy could in theory improve that and that could be sufficient.
 

A.B.

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It's probably important to distinguish in discussions about psychotherapy between mainly biological conditions and mainly psychological conditions: if your mood for example is the main problem, an intervention like psychotherapy could in theory improve that and that could be sufficient.
The idea that we can distinguish between psychological and biological conditions is an illusion.
 

Dolphin

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Dolphin said:
It's probably important to distinguish in discussions about psychotherapy between mainly biological conditions and mainly psychological conditions: if your mood for example is the main problem, an intervention like psychotherapy could in theory improve that and that could be sufficient.
The idea that we can distinguish between psychological and biological conditions is an illusion.
That's one way of looking at it. I still think sometimes a useful distinction can be made in practice.

If a therapy is supposed to improve depression or anxiety, it can be hard to find biological measures to objectively assess such an intervention. One tends to be forced to use questionnaires.

I wrote what I did partly in replying to your vague statement:
There are studies which claim to show that psychotherapy is more effective than placebo.
Questionnaires could be sufficient to validate this claim with mood disorders (I'm guessing it is this sort of evidence the claim is based on). I don't find them sufficient with ME/CFS just as I wouldn't with multiple sclerosis/cancer/cystic fibrosis/motor neuron disease.

Eventually we might have objective measures for everything incl. anxiety, depressive, complusive hand washing, agoraphobia, etc. At the moment, I think it's much more reasonable to accept the use of questionnaires as outcome measures for some conditions rather than others. Maybe a purist can find it unfair.

Related to this: I find it much more plausible that depression/anxiety/compulsive hand washing/agoraphobia could be effectively treated by a talking therapy than multiple sclerosis/cancer/cystic fibrosis/motor neuron disease. Some people, e.g. Louise Hay, may not.
 

Esther12

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It does seem that a lot of people with problems un-amenable to talking therapies get given diagnoses like anxiety/OCD/etc.

I think that a lot of these conditions could have similar political problems to those that surround CFS: lots of people with different problems being lumped in together, exaggerated claims being made about the efficacy of psychological treatments, a tolerance for managing patients with misleadingly positive claims about their control over symptoms, public views of these disorders being shaped by those with less serious problems who are more likely to recovery, etc, etc.

I wonder how much of the increased animosity around CFS as opposed to those other conditions is a result of those with traditional mental health diagnosis feeling that they and their minds are less worthy of respect, so are more accepting of quackery? Also, conditions like OCD, anxiety, etc, can leave patients feeling as if they cannot really control their thoughts, and that they want to have their minds medicalised, which is not the case for most with CFS. At the same time, it also seems that a lot of people with depression, anxiety, OCD, etc think that the health care they get is shit (this is just my impression from comments posted on-line on forums, medical sites, etc - also there was that paper showing psych professionals got the lowest ratings from their patients).

There is probably a danger that those who are able to spend a lot of time researching this stuff, are also those who make their money from claiming to be mental health experts. It will rather bias things in favour of the interests of those who want to claim to be mental health experts.

(I was tempted to delete this post, as it's such a complicated topic, I've only read around the topic a little, I'm not at all sure what I think about a lot of these things, and am feeling too tired to really explain myself. It's also a bit OT).