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When Therapy Makes Things Worse

Spending time with friends and family, exercise, and volunteer work are often more helpful than long conversations about one’s anxieties and grievances.

· 9 min read
When Therapy Makes Things Worse
Photo by Nik Shuliahin / Unsplash

In 2006, for the first time in my life, I could afford a therapist. Every week, for a “fifty-minute hour,” she lent me her full attention. If I bored her with my repetition, she never complained. She was a pro. She never made me feel self-absorbed, even when I was. She let me vent. She let me cry. I often left her office feeling that some festering splinter of interpersonal interaction had been eased to the surface and plucked.

She helped me realize that I wasn’t so bad. Most things were someone else’s fault. Actually, many of the people around me were worse than I’d realized. Together, we diagnosed them freely. Who knew so many of my close relatives had narcissistic personality disorder? In quick order, my therapist became a really expensive friend, one who agreed with me about almost everything and liked to talk smack about people we (sort of) knew in common.

I had a great year. My boyfriend proposed marriage. I accepted. And then, a month before we were due to get married, my therapist dropped a bomb: “I’m not sure you two are ready to get married. We may need to do a little more work.”

I felt the demoralizing shock of having walked into a plate-glass door.

My therapist was a formidable woman. She had at least fifteen years on me, a doctorate in psychology, and an apparently strong marriage of long duration. She dropped casual references to never missing Pilates. I once caught her at her spotless desk before our session, eating a protein bar she’d carefully unwrapped, and marveled at her obvious self-mastery, the dignity she managed to bring to our silly modes of consumption.

Maybe I should have been thrown into crisis by her pronouncement, but for whatever reason, I wasn’t. For all her training, she was still human and fallible. I had already moved across the country by myself, set up a new life in Los Angeles, and by then I knew: I didn’t agree with her assessment, and I didn’t need her permission, either. I left her a voicemail expressing my gratitude for her help. But, I said, I would be taking some time off.

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A few years later, happily married, I resumed therapy with her. Then I tried therapy with a psychoanalyst for a year or so. Every experience I’ve had with therapy has fallen along a continuum from enlightening to unsettling. Occasionally, it rose to the level of “fun.” Learning a little more about the workings of my own mind was at times helpful and often gratifying.

When I agreed with my therapist, I told her so. When I didn’t, we talked about that. And when I felt I needed to move on, I did. Which is to say: I was an adult in therapy. I had swum life’s choppy waters long enough to have gained some self-knowledge, some self-regard, and a sense of the accuracy of my own perceptions. I could pipe up with: “I think I gave you the wrong impression.” Or, “Maybe we’re placing a little too much blame on my mom?” Or even, “I’ve decided to terminate therapy.”

Children and adolescents are not typically equipped to say these things. The power imbalance between child and therapist is too great. Their sense of self is still developing. They cannot push back on a therapist’s view of their families or of themselves because they have no Archimedean point; too little of life has gathered under their feet.

Nevertheless, parents my age have been signing up their kids and teens for therapy in astonishing numbers, even prophylactically. I’ve talked to moms who hired therapists to help their kids adjust to preschool or to process the death of a beloved cat. One mom told me she put a therapist “on retainer” as soon as her two daughters reached middle school, “so they would have someone to talk to about all the things I never wanted to talk about with my mom.”

A few moms told me, using roundabout verbiage, that they had hired a therapist to surveil a surly teen’s thoughts and feelings. The therapist doesn’t disclose what the daughter says exactly, the moms assured me, but she sort of lets the mother know that everything’s okay. And occasionally, I gathered, the therapist relayed to Mom specific information gleaned from the little prisoner of war.

If the notion of “therapy” here seems vague, that’s largely to do with the experts. The American Academy of Child and Adolescent Psychiatry offers a tautology in place of a definition. What is “psychotherapy”? “A form of psychiatric treatment that involves therapeutic conversations and interactions between a therapist and a child or family.” The American Psychological Association offers a similarly circular definition: “any psychological service provided by a trained professional.”

What’s a clock? A device for measuring time. What’s time? Something measured by a clock. Any conversation a therapist has with a patient counts as “therapy.” But you get the idea: conversations about feelings and personal problems styled as medicine.

Parents often assume that therapy with a well-meaning professional can only help a child or adolescent’s emotional development. Big mistake. Like any intervention with the potential to help, therapy can harm.

Any time a patient arrives at a doctor’s office, she exposes herself to risk. Some risks arise through physician incompetence; others through negligence. An operation might proceed swimmingly, but the patient develops an opportunistic infection at the surgical site. Or everything goes according to plan, but the entire treatment was based on a misapprehension of the problem.

“Iatrogenesis” is the word for all of it. From the Greek—iatros (healer) + genesis (origin)—iatrogenesis refers to the phenomenon by which a healer harms a patient in the course of treatment. Most often, it is not malpractice, though it can be. Much of iatrogenesis occurs not because a doctor is malicious or incompetent but because treatment exposes a patient to exogenous risks.

Iatrogenesis is everywhere—because all interventions carry risk. When a sick patient submits to treatment, the risks are typically worth it. When a well patient does, on the other hand, the risks often outweigh the potential for further improvement.

And here, what I’m calling an “intervention” is any sort of advice or corrective you would typically give only to someone with a deficiency or incapacity. So, telling kids to “eat vegetables” or “get plenty of sleep” or “spend time with friends” may be advice, but it isn’t an intervention. We all need to do those things.

With interventions, a good rule of thumb is: Don’t go in for an X-ray if you don’t need one. Don’t expose yourself to the germs in an emergency room just to say hello to your doctor friend. And—just maybe—don’t send your kid off to therapy unless she absolutely requires it. Everyone knows the first two; it’s the last one that may surprise you.

For decades, the standard therapy offered to victims of disaster—terrorist attacks, combat, severe burn injuries—was the “psychological debriefing.” A therapist would invite victims of a tragedy into a group session in which participants were encouraged to “process” their negative emotions and recognize the symptoms of post-traumatic stress disorder (PTSD), while being discouraged from discontinuing therapy. Yet study after study has shown that this bare-bones process is sufficient to make PTSD symptoms worse.

Therapy can cause a client to understand herself as sick and rearrange her self-understanding around a diagnosis. It can also encourage family estrangement: It’s all Mom’s fault and you never want to see her again.

Well-meaning therapists often act as though talking through your problems with a professional is good for everyone. That isn’t so. Nor is it the case that as long as the therapist is following protocols, and has good intentions, the patient is bound to get better.

Any intervention potent enough to cure is also powerful enough to hurt. Therapy is no benign folk remedy. It can provide relief. It can also deliver unintended harm and does so in up to 20 percent of patients.

Therapy can lead a client to understand herself as sick and rearrange her self-understanding around a diagnosis. Therapy can encourage family estrangement—coming to realize that it’s all Mom’s fault and you never want to see her again. Therapy can exacerbate marital stress, compromise a patient’s resilience, render a patient more traumatized and depressed, and undermine her self-efficacy so she’s less able to turn her life around. Therapy may lead a patient by degrees—sunk into a leather sofa, well-placed tissue box close at hand—to become overly dependent on her therapist.

This is true even for adults, who in general are much less easily led by other adults. These iatrogenic effects pose at least as great a risk, and likely much more, to children.

Police officers who responded to a plane crash and then underwent debriefing sessions exhibited more disaster-related hyperarousal symptoms eighteen months later than those who did not receive the treatment. Burn victims exhibited more anxiety after therapy than those left untreated. Breast cancer patients have left peer support groups feeling worse about their condition than those who opted out. And counseling sessions for normal bereavement often make it harder, not easier, for mourners to recover from loss.

When it comes to our psyches, we’re a lot more bespoke than mental-health professionals often acknowledge or allow. And Tuesdays at four p.m. may not be when we’re ready to confront our woes with a hired expert. Reminiscing with a friend, cracking a joke with your spouse you wouldn’t dare make with anyone else, or helping your cousin box up her apartment (without talking about your problems) often aid recovery far more than sitting around in a room full of sad people. Therapy can hijack our normal processes of resilience, interrupting our psyche’s ability to heal itself, in its own way, at its own time.

Individual therapy can intensify bad feelings, too. Psychiatrist Samantha Boardman wrote candidly about a patient who quit therapy after a few weeks of treatment. “All we do is talk about the bad stuff in my life,” the patient told Boardman. “I sit in your office and complain for 45 minutes straight. Even if I am having a good day, coming here makes me think about all the negative things.” Reading that, I remembered saving up emotional injuries to report to my therapist so that we would have something to talk about at our session—injuries I might have just let go.

An embarrassing number of psychological interventions have little proven efficacy. They have nonetheless been applied with great enthusiasm to children and adolescents.

Unwanted Events and Side Effects in Cognitive Behavior Therapy - Cognitive Therapy and Research
Side effects (SEs) are negative reactions to an appropriately delivered treatment, which must be discriminated from unwanted events (UEs) or consequences of inadequate treatment. One hundred CBT therapists were interviewed for UEs and SEs in one of their current outpatients. Therapists reported 372 UEs in 98 patients and SEs in 43 patients. Most frequent were “negative wellbeing/distress” (27% of patients), “worsening of symptoms” (9%), “strains in family relations” (6%); 21% of patients suffered from severe or very severe and 5% from persistent SEs. SEs are unavoidable and frequent also in well-delivered CBT. They include both symptoms and the impairment of social life. Knowledge about the side effect profile can improve early recognition of SEs, safeguard patients, and enhance therapy outcome.

Even when patients’ symptoms are made objectively worse by therapy, they tend to assume the therapy has helped. We rely largely on how “purged” we feel when we leave a therapist’s office to justify our sense that the therapy is working. We rarely track objective markers—for example, the state of our career or relationships—before reaching a conclusion.

Sometimes when our lives do improve, it’s not because the therapy worked but because the motivation that led us to start therapy also led us to make other positive changes—such as spending more time with friends and family, reconnecting with people we haven’t heard from in a while, volunteering, eating better, and getting more exercise.

Adapted, with permission, from Bad Therapy: Why the Kids Aren’t Growing Up, by Abigail Shrier. Published by Sentinel, an imprint of Penguin Random House LLC. Copyright © 2024 by Abigail Shrier.

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