When I finished medical school, like all graduates I took the Hippocratic Oath to do no harm. Primum Non Noncere. At the time, I remember laughing with my friends. Doesn’t this set the bar a little low? We had spent years training how to help and heal people. Wasn’t it a given that we would not do harm?
Ideally, but not always.
Harm is sometimes unavoidable. Even routine interventions and procedures have untoward side effects and potential complications. Surgery exposes patients to risks of anesthesia and infection. A colonoscopy can perforate the bowel. A simple blood draw can result in a hematoma. Medications can be life-saving but can also lead to adverse outcomes. Just watch a commercial for medication and pay attention to the part when the narrator starts talking really quickly.
During my psychiatry residency we learned a great deal about adverse outcomes and side effects of medications. How SSRIs could induce a manic episode. How clozapine could cause agranulocytosis. How lithium could impact kidney function. Drug interactions were another concern. We warned patients about mixing benzodiazepines with alcohol because it could depress breathing. We avoided carbamazepine in patients on birth control pills because it could lower their effectiveness. We told patients who were taking the anti-anxiety medication buspirone to not drink grapefruit juice because it can increase the amount of medicine in the blood.
What we never spoke about or learned about was how psychotherapy could be harmful.
Why would we? It seems bizarre to even question whether it could be problematic or have side effects. After all, psychotherapy is only talking.
What could possibly go wrong?
While demonstrably effective in many cases, psychotherapy is not without risk. It can result in undesirable side effects such as emotional distress, symptom exacerbation, and therapist-induced harm. In depression, about 5 percent of depressed patients get worse in psychotherapy, compared with 12 to 13 percent who get no treatment at all. Therapy wins that comparison. But adverse events have been reported to impact about 1 in 10 people undergoing psychotherapy, and serious adverse events 1 in 21. In an article entitled The Elephant on the Couch, the authors discuss how psychotherapy can turn a patient’s illness into an identity and replace real world problems with endless introspection. It can also shift the locus of control outward so that present difficulties get blamed on other people, especially parents.
As highlighted in a recent Wall Street Journal article, a growing number of patients are being advised by therapists to cut off parents they deem to be toxic. In a survey of 7000 estranged parents, a third believed a therapist recommended or influenced the rift. While most therapists agree that cutting off ties with a family member who has been physically and emotionally abusive is sometimes warranted, what has changed is how abuse is defined.
“We are in a culture where we emphasize fragility, everything becomes trauma, and the solution increasingly is to split and leave,” says William Doherty, a therapist and professor emeritus of family social science at the University of Minnesota who has researched the ways that therapy may be harmful. “But it should be the tragic exception that you cut off a parent or loved one, not business as usual in therapy.”
Karl Pillemer’s research at Cornell shows that people who initiate a cutoff feel temporary relief and then experience significantly higher rates of chronic unhappiness and depression over time. He calls this “the exiter cost.” Cutting ties with family leaves many feeling even worse in the long run and severs them from their greatest source of support.
The talking cure?
A study found that inviting a person to talk about their parents in therapy can distort memories of childhood. Researchers at the University of Portsmouth asked people to recall a recent example of their mother highlighting either a positive or negative quality. Those simple prompts shifted how participants felt about her in the present and also what they remembered feeling towards her as children. The lead author Lawrence Patihis warns that therapists who tend to trace present problems back to childhood can distort memories. It is not surprising to think that fixating on what was wrong with one’s upbringing might make it hard to remember the good times. Patihis argues that patients should be warned upfront that therapy can alter how we think about the past.
“Some therapies that focus on childhood reappraise parents negatively, because the assumption is that relationship problems you have in the present are the result of trauma from childhood. But our research supports existing evidence that this process can sometimes manipulate the truth of what people actually felt in the past. The concern is that this can result in a family growing distant from one another in the present.”
Good enough used to be enough
The “good enough mother,” a parenting concept coined in 1953 by British pediatrician and psychoanalyst Donald Winnicott posited that a child does not need a perfect mother. In fact, an imperfect one can help a child grow and blossom. As long as the child knows that they are loved and cared for, Winnicott believed, they can thrive with a good enough mother or parent.
Today, the parenting industrial complex tells a different story. We are led to believe that if a parent does not validate every feeling and does not repair after every rupture, the child will be irreparably damaged. Parenting magazines tell us that common phrases parents often use might be harming children. According to a recent article, telling a child “you’re ok,” “hurry up,” “practice makes perfect” and “great job” may negatively impact their self-esteem and discourage independence. All of these phrases used to roll off my parents’ tongues. I cannot help but wonder that if I was told that they were harmful that I would have interpreted them as harmful.
If parents don’t say exactly the right thing at exactly the right time, we worry our children are doomed. The rise in perfectionism in kids gets a lot of attention. I also worry about the pressure for parents to be perfect too. Kids expect perfection from their parents and parents are working overtime to get it right. We have created impossible standards. Of course parents will fall short and many of these children will end up in therapy complaining that their parents were not good enough. It is no wonder that they are so stressed out.
I have no doubt that talking to a therapist can be helpful in many cases but not always. I would argue that the quality of the therapist matters most of all.
Do they agree with everything you say? Do they encourage you to blame others? Do they invite you to fixate on past grievances? Do they allow your feelings to be facts? Do they foster dependency on them? Do they want to be your friend? Do they expect you to be in treatment forever?
Or do they ask you to take responsibility? Do they encourage you to assume positive intent? Do they inquire about what you’re looking forward to? Do they remind you to seek perspective and not jump to conclusions? Do they ask you about your strengths and what you are like at your best? Are they future focused?
As Nobel prize winner Daniel Kahnemann said, “Nothing in life is as important as you think it is, while you are thinking about it.” Find a therapist who helps you see potential and possibility.
