“Psychotherapy Is Not Harmless”
This is a sentence that I came across recently while reading a paper on adverse effects in Cognitive Behaviour Therapy (CBT).
The sentence stayed with me. Not because I think CBT is bad or that we should stop using it.
And certainly not because I think psychodynamic therapy, ACT, EMDR, mindfulness, or any other approach is somehow immune from potential negative effects.
What struck me is how rarely I hear this discussed.
I have worked in mental health for 25 years across two countries.
I have heard CBT described as the “gold standard” countless times.
I have heard people talk about evidence, effectiveness, symptom reduction, treatment guidelines, and outcomes.
What I don’t remember hearing very often is a discussion about adverse effects.
Yet the literature is there.
Schermuly-Haupt, Linden and Rush (2018) note that even appropriately delivered psychotherapeutic interventions can have unwanted or adverse effects. These may include symptom worsening, increased distress, strains in relationships, dependency, and other unintended consequences.
This should not surprise us.
Every powerful intervention has the potential to help and the potential to cause harm.
The more interesting question, at least for me, is not whether CBT can have adverse effects. The literature already suggests that it can.
The questions that interests me are these:
Can some therapeutic interventions accidentally teach people to endure rather than resolve?
Can they teach people to contain rather than process or resolve difficult material?
Can they help people adapt to situations that perhaps should be changed?
Before anyone gets upset, I am not saying CBT does this all the time.
I am asking whether it can happen sometimes.
One of the papers I read recently was by Gross and John (2003), who distinguish between reappraisal and suppression. Both are ways of responding to difficult experiences, but they are associated with very different outcomes. Reappraisal is generally associated with better psychological functioning and interpersonal outcomes, whereas suppression appears to come with significant costs.
That distinction seems important.
When a client learns to challenge a thought, are they becoming more flexible?
Or are they learning to push the thought away?
When a client learns to cope, are they becoming more resilient?
Or are they learning to endure circumstances that perhaps should be confronted, changed, grieved, or resolved?
Hayes and colleagues (1996) discuss the concept of experiential avoidance: the attempt to avoid unwanted thoughts, emotions, memories, or bodily experiences. One observation from that paper particularly stood out to me:
Experiential avoidance appears to work even when it doesn’t.
In the short term, suppression often seems to succeed.
Distraction can reduce distress.
Avoidance can provide relief.
Pushing difficult thoughts away can help us function.
The problem is that short-term effectiveness and long-term effectiveness/benefits are not always the same thing.
The very strategies that help us survive may eventually restrict our lives and internal experiences.
A related point was made by Wegner (1994), whose work on thought suppression demonstrated the paradoxical finding that attempts not to think certain thoughts can sometimes make them more persistent.
Another potential harm of therapy is not dramatic. It may happen quietly, when a person’s complex story is reduced too quickly to a model, symptom, formulation, protocol, or technique. In narrative terms, therapy can replace a ‘thick’ description with a ‘thin’ one (White & Epston, 1990). In epistemic terms, it can fail to treat the client as a knower of their own experience (Fricker, 2007).
Interestingly, some of the most relevant observations come from within the CBT literature itself.
Arch and Craske (2008), comparing CBT and Acceptance and Commitment Therapy, note that cognitive restructuring and acceptance-based approaches may, under certain circumstances, risk thought suppression even while aiming to reduce avoidance. They explicitly discuss the possibility that CBT techniques may encourage thought or emotional suppression.
That is not a criticism from outside the CBT tradition, but a discussion occurring within the broader cognitive-behavioural literature itself.
To be clear, I am not arguing that CBT is uniquely problematic.
Every therapeutic model has strengths, as well as blind spots.
Psychodynamic therapy can become intellectualisation. Mindfulness can become detachment. Acceptance can become resignation. Insight can become nothing more than insight, without meaningful (behavioural) change.
Any therapeutic approach can become defensive when applied rigidly.
The question is not which therapy is perfect.
The question is whether we are willing to discuss the limitations and unintended consequences of the approaches we use.
CBT’s contribution to psychology is evident.
Acknowledging that psychotherapy can have adverse effects does not weaken psychotherapy. If anything, it strengthens it. Because mature professions do not protect treatments from scrutiny, but invite it instead.
Perhaps it is time that conversations about psychotherapy include not only what works, but also what can go wrong.
Not because therapy is dangerous, but because it is powerful.
Selected references
Arch, J. J., & Craske, M. G. (2008). Acceptance and Commitment Therapy and Cognitive Behavioral Therapy for Anxiety Disorders: Different Treatments, Similar Mechanisms?
Fricker, M. (2007). Epistemic Injustice: Power and the Ethics of Knowing.
Gross, J. J., & John, O. P. (2003). Individual Differences in Two Emotion Regulation Processes: Implications for Affect, Relationships, and Well-Being.
Hayes, S. C., Wilson, K. G., Gifford, E. V., Follette, V. M., & Strosahl, K. (1996). Experiential Avoidance and Behavioral Disorders.
Schermuly-Haupt, M.-L., Linden, M., & Rush, A. J. (2018). Unwanted Events and Side Effects in Cognitive Behavior Therapy.
Wegner, D. M. (1994). Ironic Processes of Mental Control.
White, M., & Epston, D. (1990). Narrative Means to Therapeutic Ends
Aliz Ovlachi - Clinical Psychologist & Author 