Can therapy be bad for you? There’s a strange omission in the way we tend to talk about psychotherapy, which has come to be regarded in the culture as a sort of unalloyed good, something almost everyone should have a go at.
We are happy to accept that this interaction – a conversation between therapist and client – is capable of changing our psychology in positive ways, even “transforming lives”. But we don’t extend the logic. If therapy is so powerful, isn’t there a risk it can harm us too?
Last week, psychotherapy came in for a rare bit of scrutiny after a media furore surrounding Jonah Hill, the Hollywood actor-producer. While dating a former girlfriend, he allegedly sent her a string of texts asking that she remove bikini pictures from social media, stop “surfing with men”, and avoid female friends “in unstable places” who had not been first approved of by Hill. What particularly caught the eye, though, was the language he seemed to use. His supposed list of unreasonable demands were rebranded, in the texts, as “boundaries”, a word typical of therapy-speak. Hill has been open about his experiences of therapy (he even made a Netflix documentary about his shrink). But was the therapy the right treatment for Hill, or was it merely equipping a controlling man with ways to emotionally abuse his partner?
We seldom hear about therapy that leaves patients, or those around them, worse off than where they started. But the evidence is there. Some 5-7% of clients deteriorate after treatment: old symptoms get worse, new ones appear and people become dependent on their therapists. Incompetent practitioners might be one part of the problem (botching a process in which a client relives unpleasant memories, for example, could harm them). Malicious therapists might be another. Jobs that deal with vulnerable people, such as social care and nursing, can attract predators as well as saints.
This shouldn’t be a surprise. Vulnerable people require careful handling. It is easy to see how a cackhanded attempt to transform the thinking patterns of someone suffering from depression, say, could tip them in the wrong direction.
It’s not just the quality of the therapist, though. There is also the problem of matching treatment to patient, a matter on which there seems to be few established guidelines. Not everything works for everyone. Mindfulness is billed as an innocuous sort of therapy. Yet one recent review of mindfulness lessons in secondary schools found it prompted no change in the mental health of students other than to make those with existing symptoms slightly worse.
There is less research into the harms that therapy might do to friends or relatives of clients, as may have been the case with Hill and his former girlfriend. It might be possible for a treatment to make patients feel better, researchers speculated, but which increases the rates of false accusations against family members. But this wouldn’t show up in assessments; the idea of measuring or effects that go beyond the client has yet to take much hold in the profession.
There are problems with evidence all round. Glenys Parry, emeritus professor of psychological services research at the University of Sheffield, says there is an “allegiance bias”, where psychotherapists conducting research trials tend to find results that favour their own brand of treatment. A 2017 review of how research evidence has been summarised found that only a few of them met the highest standards of unbiased analysis.
It is only recently, too, that researchers have become interested in the idea that therapy might have adverse effects. A book published in 2003 that became the psychotherapist’s bible, Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change, devotes just two out of 800-plus pages to it. A consequence, perhaps, of a field left largely to examine itself.
How to solve the problem? Funding more research into therapy’s harms would be one idea. Getting rid of the UK’s unregulated therapists would be another. There is no UK law against setting yourself up as a counsellor or therapist, and reporters have found it easy to cheat their way through online courses. A profusion of new therapy apps may have added to the problem, exposing more people to unfit therapists. Horror stories about the app BetterHelp recently surfaced on TikTok: therapists being late, taking calls during sessions or ghosting their clients – or even, in one case, congratulating on losing weight a patient with an eating disorder.
But even signing up to a reputable organisation such as the British Association for Counselling and Psychotherapy (BACP) doesn’t necessarily get rid of an incompetent shrink. The BACP asks practitioners to agree to a code of ethics, such as keeping accurate records, protecting confidentiality and not causing clients harm. But harm is defined loosely and may be difficult for therapists to judge when it is caused by something as intimate as a bad personality fit with the client.
Enforcing these ethics is also hard to do. The main route is through patients complaining to the organisation with which their therapist is registered. But this may not be widely known to people undergoing therapy; therapists are not obliged to tell their clients about the option, nor are they incentivised to do so. Meanwhile, it may be difficult for patients themselves to determine whether they are being harmed – negative feelings are often part of the therapeutic process.
Statutory regulation might be a solution worth trying. This would have more heft than voluntary registers and would get rid of unlicensed therapists. But the idea that therapy can do harm in the first place could do with greater currency. Therapy deserves to be taken seriously as a medical treatment. And any medicine worth the name can be dangerous too.
• Martha Gill is an Observer columnist
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