By:

Dr. Hani Hamed Dessoki, M.D. PsychiatryAssociate Prof. Psychiatry

Acting Head, Psychiatry Department

Beni Suef University

Luxor

2013

Agenda History

Introduction

Prospectives on psychotherapy

Suicide and Psychotherapy

How could psychotherapy ever be harmful?

Negative effects of psychotherapy

Definition of Psychotherapy

A classic definition of psychotherapy is use of interpersonal influence skills and psychological techniques by trained professionals toward the goal of relieving the signs and symptoms of psychiatric disorder.

Psychotherapy is defined as a “procedure,” similar to that of a medical procedure.

History

The possibility of treatment-induced deterioration among psychiatric patients was first observed nearly 7 decades ago (Masserman & Carmichael, 1938).

Psychotherapy can sometimes be harmful: (a) deterioration effects and (b) negative effect

Introduction

Effective treatment causes side effects; this applies for medical interventions and psychotherapy alike.

Due to its specific setting it is unusual to focus on risks and damages within psychotherapy.

Introduction

When ascertaining negative effects from treatment, one might look for slower response, less remission or recovery, higher rates of relapse or recurrence, or some combination of these.

In contrast to all the pharmacotherapy studies, there is precious little information about the safety of psychotherapeutic interventions -- which are also, in some patients and in some instances, associated with adverse events that need to be noted.

These may include undue stress and potential overstimulation.

Both of these issues may contribute to the potential for symptom exacerbation.

Introduction

Psychology, 4/e by Saul Kassin ©2004 Prentice Hall

Perspectives on PsychotherapyThe Bottom Line: Does Psychotherapy Work?

Based on the results of 475 studies (Smith et al., 1980), the average psychotherapy client shows more improvement than 80% of those in the no-treatment control group.

The Benefits of Psychotherapy

Psychology, 4/e by Saul Kassin ©2004 Prentice Hall

Perspectives on PsychotherapyWhat is the Future of Psychotherapy? Orientations of Psychotherapists

Eclectic: Borrowing ideas and techniques from different approaches

Prroblems

Empirical research on the negative effects of psychotherapy is insufficient, partly because there is a lack of theoretical concept on how to define, classify and assess psychotherapy side effects.

Introduction

On the other hand most clinical studies reported a complete lack of side effects of psychotherapy and related therapies, like cognitive-behavioural treatments, also in schizophrenia, behavioural treatments, hypnotherapy, hypnosis, alcoholics anonymous.

Paradoxal findings: Psychotherapy diminishes side effects

A number of the studies found associated paradoxically psychotherapy to the reduction of side effects of other treatments.

This indicates that psychotherapy in general is balancing the patient and helping the patient with physical, mental, existential and sexual problems.

Suicide and Psychotherapy

Suicide is normal in the mentally ill population, but there is no documentation that psychotherapy provokes suicide; quite contrary it seems therapy with intimacy and closeness between therapist and patient can prevent suicide.

Suicide and Psychotherapy

Sometimes, although rarely, mentally patients did commit suicide during psychotherapeutic treatment caused by their mental illness not their therapy.

In comparison, psychiatric treatment with drugs is known to provoke suicide in 2% in the beginning of treatment .

How could psychotherapy ever be harmful?

Negative side effects for a therapeutic technique is the use of breathing retraining and relaxation procedures during exposure-based procedures for individuals with panic disorder with agoraphobia.

Just because a therapeutic technique is useful in one situation — outside of exposure procedures, for instance, to help reduce anxiety or tension — doesn’t mean it might not be harmful in other situations.

In addition, there have been increased reports of family conflicts, with aggressive or suicidal behavior in people undergoing various psychotherapeutic interventions.

How could psychotherapy ever be harmful?

Psychotherapy among patients with OCD

Although very effective for reducing the frequency and severity of OCD symptoms, many people undergoing psychotherapy, such as cognitive behavior therapy (CBT) and exposure and response prevention (ERP), notice that a side effect of treatment is that their anxiety actually increases in the beginning stages of therapy.

“Side effects” of psychotherapy are unpredictable

In psychotherapy, you never know what to expect.

Any behaviour modification technique can be misused or misapplied.

"positive thinking" can actually have a negative impact on the mental health of some people (and this has been known for years in regard to trauma counselling and sexual assault counselling).

The negative effects of psychotherapy

Psychotherapy can lead to the occurrence of new symptoms or problems which are not themselves resolved in the course of management.

The negative effects of psychotherapy

The clients will go through a period of feeling worse as their old habits of coping are replaced with new strategies and ways of thinking.

This process can temporarily highten anxiety and insecurity and negative thoughts, feelings of helplessness, hopelessness etc.

The negative effects of psychotherapy

Acquiring new symptoms

Worsening of symptoms (3-10%) and regression

Depdendence

False memories

Superficial insight (acquiring empty language)

Iatrogenic malingering

Causes of negative effects of psychotherapy

Negative effects may be due to techniques, client variables, therapist variables, or some combination of these.

Psychotherapy and Informed Consent

Informing clients about the potential risks and benefits of psychotherapy is a fundamental component of obtaining informed consent, analogous to a physician’s informing a patient about the risks and benefits of medication or treatment.

Difficulties

The lack of consensus in existing literature related to what constitutes negative effects of psychotherapy reflects the conceptual complexities in this area.

One classic definition states that negative effects occur “when there is no meaningful positive change in a client due to some aspect of the treatment process”.

The most extreme negative effect is related to “client deterioration in functioning that is attributed to the course of therapy”.

Indicators of Potential Deterioration

The five indicators for “potential deterioration,” as a result of interaction between therapeutic techniques, psychotherapists, and clients include, (a) the role of anticipation of emotional pain and therapeutically induced arousal

(b) client suspiciousness toward the therapist and therapist empathy

(c) level of interpersonal functioning and the focus of treatment

(d) diagnosis and treatment modality

(e) relaxation therapy and clients’ need for control

Termination

Over 4-6 monthly sessions

Review patient success

Discuss potential vulnerabilities

– Identify strategies for management of interpersonal difficulties and symptom relapses

Encouragement about ability to use strategies independently

Psychotherapy and Pharmaceutical Companies

Drug companies have been sold on the idea that their troubles stem from a "chemical imbalance," the solution to which, of course, involves rebalancing their chemicals, just like diabetics taking insulin.

Biopsychosocial model

The biopsychosocial model (abbreviated "BPS") is a general model or approach positing that biological, psychological (which entails thoughts, emotions, and behaviors), and social factors, all play a significant role in human functioning in the context of disease or illness.

Indeed, health is best understood in terms of a combination of biological, psychological, and social factors rather than purely in biological terms

Biopsychosocial model in depression

The model stresses the self-evident integration of biological and psychological therapeutic interventions that need to focus on symptom reduction and on relapse prevention.

Effective treatment of severe or chronic unipolar depression requires the combination of pharmacological and psychotherapeutic interventions.

Schotte et al., 2006;23(5):312-24

Psychotherapy

Psychotherapy focuses on the therapeutic relationship with the client / patient as well as their social environment.

The healing process is dialogical and polylogical as well as vulnerable throughout all schools of psychotherapy.

The quality of the therapeutic relationship is central to a cure.

Recognition of adverse treatment effects is a characteristic of good therapists and treatments.

Psychotherapists should be sensitive for negative effects.

The detection and management of adverse treatment effects is not a sign of bad but of good clinical practice.

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